In the late spring of 2019, the Accreditation Council for Graduate Medical Education (ACGME) made a major change in the Common Program Requirements, eliminating core faculty time for teaching, administration, and assessment. To mitigate the impact of this, the Family Medicine Residency Committee added a requirement for an Associate Residency Director. For an average size family medicine residency, the net effect was an approximately 50% reduction in total faculty time required for residency administration, education, and assessment. In addition, the ACGME Common Program Requirements eliminated the requirement that residents take a board examination and lowered the standard for the rate of passing for those who do take the examination. To assess the impact of these changes, American Board of Family Medicine (ABFM) surveyed family medicine residency directors in July 2020. To get the results to the community as quickly as possible, this short report summarizes results and implications.
Methods
ABFM directly surveyed the 687 Family Medicine residency directors. As shown in Table 1, survey questions were framed in a neutral way. The Association of Family Medicine Residency Director leadership encouraged completion of the survey. Analysis included simple frequency descriptions and thematic analysis of adverse impact. A code book was developed, and open-ended verbatim comments were analyzed independently by 2 former residency directors with personal experience in the Family Medicine Review Committee, with discussion to achieve consensus on specific themes in each comment. Reviewers limited analysis to reports of actual changes, rather than speculation about possible changes. An hoc task force of the American Board of Family Medicine Board of Directors met to review the verbatim responses, identify additional themes and consider the implications of the results.
Questions on Impact of ACGME June 2019 Changes
Results
Response rate was 52.8% or 363 out of 687. Of those, 194 reported changes since June 2019: 8.2% of program directors (PDs) reported that there had been positive changes since June 2019, chiefly in increased faculty development because of Associate PDs; and 11.9% reported discussion with their institutional sponsors with confirmation of their current budget and faculty roles. Seventy-five percent or 146 reported significant and adverse impact since June of 2019, with a large majority (69.9%) reporting immediate and direct changes in budget and faculty time allocations as the result of the changes. Others reported loss of faculty involvement in assessment, mentoring, and remediation; in curriculum development and delivery; in clinical supervision, in faculty development; and in scholarship. Almost 40% reported increased burnout of faculty or the PDs themselves. An additional 9 (6.2%) reported the likelihood of an imminent cut in budget or faculty time allocation. Table 2 lists key themes, proportion of residency directors endorsing each theme, and representative quotations. Of note, most comments included more than 1 adverse impact.
Adverse Impact of ACGME 2019 Changes: Key Themes, Frequency, and Representative Quotations
With respect to lowered standards for cognitive expertise, only 5.1% (18) reported any immediate impact on their residencies. Most comments indicated that PDs (PDs) had not changed their approach and kept higher standards for taking and passing a board examination. Two PDs reported that the change was beneficial: “we have been more willing to consider matching students who have had testing difficulties” and “we are more able to consider other characteristics like purpose in coming and connection to our mission and our community.” One PD connected both ACGME changes: “(I) guess… the ACGME are lowering their passing standards since they are no longer protecting teaching,” and one PD reported that their hospital had stopped paying for the test because of the removal of standards for taking the examination.
Discussion
Our results provide important evidence that the ACGME June 2019 changes in program requirements for family medicine have had a substantial adverse impact on the learning environment of family medicine residencies. Sponsoring institutions responded to the ACGME changes rapidly. The harm was broad and deep—primarily rapid changes in budget and faculty time allocation for administration, assessment and education, but it also affected many core functions of residency education, assessment and remediation of residents, participation in didactics, clinical supervision, faculty development, and scholarship.
Response rate was only 52%. However, this was almost all achieved in a week, suggesting the importance of the topic, and the absolute numbers programs responding (363), and the high numbers of those reporting significant adversely impact (146), are substantial in their own right, representing a large proportion of Family Medicine residencies. Of note, since our survey took place in July 2020, it is possible that some of the effects reported reflected the impact of Covid-19 on the finances of the hospitals and health systems, but the question explicitly anchored the changes in response to the June 2019 changes and very few mentioned the pandemic in their free text responses.
ABFM believes that dedicated time for teaching, assessment, and administration is a critical resource for the quality of residency education, that the June 2019 changes had a major negative impact on the learning environment in Family Medicine, and that this impact will grow as the financial impact of Covid-19 hits sponsoring institutions. Of note, these changes took place despite unanimous opposition from all organizations in Family Medicine to the original recommendations of the ACGME Committee on Requirements in the spring of 2019. Over the last year, after the ACGME board changed policy to allow specialty committees to define core faculty requirements, ABFM and the other organizations of family medicine unanimously supported the Family Medicine Review Committee’s proposals for core faculty time, but the ACGME Committee on Requirements deferred action and the ACGME has constituted another task force to consider the issue.
The collaboration between ACGME and American Board of Medical Specialties (ABMS) is a distinctive and very positive feature of American Medicine: the ACGME accredits residencies and the ABMS boards certify individuals. Over the past 15 years, ABFM and the Family Medicine Review Committee have worked closely together to catalyze innovation in residency education, reduce disparities of cognitive expertise for International Medical Graduates (IMGs)1 and to test the validity of milestones2 and we are working closely to bring evidence and community dialog to bear on the upcoming major revision of the residency requirements.3,4 Let us now work together to restore the learning environment in family medicine residencies.
Summary
The ACGME June 2019 changes in residency requirements are having a powerful and adverse effect on the learning environment in family medicine residencies. The ACGME has had longstanding commitment to both excellence in education and to serving the needs of the public. ABFM urges its friends and partners at the ACGME to reaffirm these principles and reconsider their June 2019 decision.
Notes
This article was externally peer reviewed.
Conflict of Interest: None.
Funding: None.
To see this article online, please go to: http://jabfm.org/content/33/6/1033.full.
- Received for publication October 23, 2020.
