Introduction

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for ensuring the quality of graduate medical education (GME) in the United States through its mission to “improve health care and population health by assessing and advancing the quality of resident physicians' education through accreditation.”¹ Residents and fellows training in accredited programs are critical partners in evaluating the effectiveness of GME, and share with the ACGME the goal of improving the clinical learning environment in which they learn, participating in care, and innovating and improving the delivery of health care.

Currently, resident and fellow trainee interaction with the ACGME is through the annual survey, accreditation site visits, Clinical Learning Environment Review (CLER) visits, and the ACGME case log system. The new accreditation system has reduced the emphasis on prescriptive process requirements, freeing programs to innovate to achieve high-quality education in a safe clinical learning environment.² This has reduced the frequency of site visits to accredited programs, and has increased reliance on annual survey data from residents and faculty to detect problems in the learning environment. A disconnect between residents and the ACGME could jeopardize the quality of this information and its value to the ACGME.

There is a dearth of information on resident perceptions of the ACGME and its accreditation function. The only relevant information available is literature on trainees' opinions about the ACGME duty hour requirements. These studies found mixed perceptions of the duty hour requirements instituted in 2011, with residents expressing concerns that the changes reduced continuity of care, lowered quality of care, decreased readiness for independent practice, and had minimal impact on individual well-being.^3–6

To enhance our understanding of what residents think about the ACGME and its role, and to identify ways to communicate the mission of the ACGME to residents, the Council of Review Committee Residents (CRCR), a 31-member multi-specialty panel of residents and fellows who serve as resident members of the various review committees, held a series of discussions about trainee perceptions of the ACGME. From this information, CRCR members created a consensus statement regarding current attitudes toward the ACGME, and a series of recommendations to assist the ACGME and the medical education community to better communicate training goals to current trainees.

Methods

At the CRCR meeting in September 2015, 28 residents (14 medical, 10 surgical, and 4 hospital-based specialties) participated in a 2-phase discussion about trainees' perceptions of the ACGME. This was formulated around several scenarios in which participants role played discussing the ACGME with fellow residents at their home institution and at a national meeting (table 1).

table 1 Imagined Scenarios With Question Prompts for Modified Fishbowl Group Interaction

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In the first stage, participants were assigned to 3 groups. Each group discussed the assigned scenario using a modified fishbowl approach.⁷ This design created a dynamic group interaction that stimulated the communication of diverse views among residents and fellows from 25 different specialties, at all stages of training, and also in osteopathic and allopathic programs. Following completion of the fishbowl discussion, each group formulated consensus opinions, which were presented to the aggregate CRCR for further discussion and refinement.

Results

The first question asked participating residents to reflect on how the ACGME affects their everyday training and working life. Consensus themes centered on the importance of the ACGME in ensuring the quality of the learning environment and protecting patient safety. Specific themes included the ACGME's role in setting and enforcing duty hour limits, ensuring the quality and safety of health care delivery, and maintaining a high standard for the profession. CRCR members then considered whether there was value in engaging residents in the mission of the ACGME. Each group identified resident engagement as essential to the proper functioning of the ACGME. Each group also affirmed that the trainee voice is necessary in the accreditation process, as trainees have direct contact with both the issues confronting their patients and the attributes of their educational program. In addition, the discussion focused on the importance of enhanced resident understanding and engagement in the mission of the ACGME to ensure honesty on the resident survey.

Next, the discussion focused on the contrast between how most residents perceive the ACGME and CRCR members' understanding of the actual function of the ACGME. Each group felt that many residents have a negative view of the ACGME, which may be worsened by certain negative faculty and program director impressions of the ACGME. Discussion of possible negative perceptions focused on themes of administrative burden, fear of retribution, ambiguity, micromanagement, and a general disconnect between resident education and ACGME regulations. The CRCR members then considered the content of the message that should be communicated. Emerging themes included serving the public good, protection of resident well-being, innovation, transparency, dialogue, collaboration, resident engagement, and the necessity of accreditation to promote program quality and patient safety.

In the final stage of discussion, residents considered current ACGME efforts to connect with residents, and made recommendations to improve ACGME outreach to and seek feedback from this group. The CRCR members did not identify any current, direct outreach to residents, and determined that most information about the ACGME is being communicated indirectly by program and institutional leadership, faculty, and fellow trainees. The members noted that some residents had acknowledged positive interactions during CLER site visits that had improved their view of the role of the ACGME. The members felt that utilizing CRCR residents, improving website functionality for activities relevant to trainees, and applying existing contact points, such as the resident survey, would improve communication with this key stakeholder group. Finally, members considered ways to provide feedback to the ACGME. In addition to the resident survey, the CRCR members felt that improving contact between the CRCR and fellow residents, and creating a resident liaison position in each sponsoring institution, may improve feedback to the ACGME (table 2).

table 2 Consensus Themes in Response to Imagine Scenario Questions

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Discussion

The discussion at the meeting highlighted a disconnect between the way most residents view the mission and values of the ACGME, and the way they are viewed by the CRCR members. Many residents perceive the ACGME as micromanaging, punitive, burdensome, disconnected, and ambiguous. This is in strong contrast to the views of the CRCR, whose members believe that the ACGME effectively improves patient safety and protects trainees. However, this message may not be reaching trainees. Having only the trainees who are intimately involved in the accreditation process understand the value of the ACGME is a missed opportunity to transform graduate medical education and improve health care.

Correcting this disconnect and better engaging residents in a shared understanding of the goals and work of the ACGME are crucial to its proper functioning. Trainees have a unique perspective on the learning environments in their hospitals and clinics, and without their input opportunities for identifying areas for improvement that will most facilitate their growth will be lost. Ensuring that residents feel invested in the ACGME and its role is also required so that they can hold their own institutions accountable to the educational standards, and feel empowered to make changes when their program is failing to meet these standards. This is particularly critical when considering the increased reliance on resident and faculty survey data for annual assessment. A shared understanding of educational goals among residents and faculty may improve the reliability of these surveys.

Achieving improved outreach to residents requires a multimodal approach, but this first requires establishing outreach as a strategic goal of the ACGME. The CRCR members agreed that personal contact through established mechanisms (program directors, designated institutional officials, and faculty) as well as new mechanisms, such as outreach by the CRCR residents and possibly a local elected resident liaison position, would be more effective than educational modules and online content.

Conclusion

A multi-specialty, nationally representative group of fellows and residents discussed current resident attitudes toward the ACGME and its accreditation role, and concluded that the resident population at large misunderstands the organization's mission, character, and goals. This may result in lower-quality information reaching the ACGME through the resident survey, thus reducing the validity of the accreditation process. The misunderstanding likely is due to the fact that resident interaction is limited to surveys and infrequent site visits, and residents' attitudes may reflect those of their faculty. The perceptions of the ACGME by this key stakeholder group can be improved with more effective outreach. Improving outreach to convey the mission, goals, and activities of the ACGME directly to residents and fellows will allow for a more collaborative effort in improving the quality of graduate medical education.