The physicians in graduate medical education are called residents; they make up a teaching hospital's house staff. Both terms* connote the historical closeness of young doctors to the teaching hospital where they are receiving their advanced clinical training. The residency prepares a physician for practice in a medical specialty; there are now 24 specialties (listed in Appendix D). In a period ranging from three to eight years, depending on the specialty, the residency imparts the knowledge and experience required for certification of the physician by one of 23 medical specialty boards. Further time in residency can lead to certification in a subspecialty, of which there now are 42. For example, graduate training in the specialty of internal medicine can lead to any of 11 subspecialties, such as gastroenterology or nephrology. Training beyond that required for board certification is often achieved in a fellowship, which typically emphasizes a path of research toward subspecialty expertise. Teaching hospitals range from smaller affiliates of academic health centers, with only a few residency programs, to major institutions that offer training in almost all of the specialties. Of the approximately 7,000 hospitals in the United States, about 1,500 have some residency prograins, and thus meet the definition of teaching hospitals. But 46 percent of all residents in the United States are trained in only 100 hospitals, which is to say that hardly more than one percent of all the hospitals in the country handle *A glossary of terms used in describing the organizations and processes of graduate medical education is in Appendix 1 of this report. : the graduate training of almost half of all medical residents (Smith and Stemmler, 1984). Graduate medical education began early in this century as apprenticeship programs in a few institutions or offices of established physicians. For many years, the majority of physicians trained to be general practitioners. : Specialty boards, which certify physicians appropriately prepared to practice a specialty, originated in 1917 with ophthalmology. Otolaryngology was next, in 1924, and then a flood of specialty boards rose-13 in the next decade. (Specialties and subspecialties are listed in Appendix II.) By the 1960s, the Federal government was developing a concern that the country had too few physicians for its future needs. Existing medical schools were encouraged to expand, and new ones were founded. Specialty training programs were opened up to receive the influx of newly graduated M.D.s. The new Medicare and Medicaid programs included provisions to pay their share of graduate medical education. Not surprisingly, the number of medical graduates seeking specialty training surged from 29,000 in 1950 to 66,000 in 1973, and then to 72,000 in 1983. The growth of graduate medical education over the years has brought a number of organizational participants into the process, but they have never integrated into a coherent system of control. Instead, a complex arrangement of partial controls variously affects the accreditation of residencies, the certification of specialists and the conduct of the programs themselves. The effects of these fragmented controls are described in the following sections. Accreditation of Residency Programs The American Medical Association (AMA) established a body in 1927 to oversee graduate medical education. During the next fourscore years the body's name was changed several times, but it remained solely under AMA control. In 1972, the body's participation was enlarged to include the American Hospital Association, the Council of Medical Specialty Soci eties, the American Board of Medical Specialties and the Association of American Medical Colleges. That body is now called the Accreditation Council for Graduate Medical Education (ACGME). It delegates its accreditation responsibilities to 24 Residency Review Committees (RRCs), one for each of the specialties. The members of RRCs are appointed by the AMA and the relevant specialty boards; in some instances, appointments also are made by a specialty society, for instance, the American College of Surgeons appoints to surgical RRCs. Appendix ! defines specialty boards and societies; Appendix III lists RRCs and their sponsoring organizations. The ACGME lays down general requirements for residency programs, and each RRC draws up particular requirements, tailored to its specialty, that follow the ACGME guidelines for faculty, administration, program content and the like. RRCs also set the minimum length of program and may further stipulate the educational procedures and the number of residents that may be in each year of training. The RRCS make alterations in their requirements as circumstances warrant. These alterations are subject to ACGME approval, but they are rarely countermanded. The five parent organizations of the ACGME and the spe cialty boards may review rules established by the RRCs, but they cannot modify or veto them. Certification of Specialists Apart from the system that accredits residency programs is the system that certifies specialists. Twenty-three specialty boards-independent bodies. -set the educational requirements whose fulfillment is necessary for a physician to be certified in a specialty. To be eligible for certification by a specialty board a physician both has to meet the education criteria and successfully complete an accredited residency program. The distinction between those two attainments is hazy but serves to establish some connection between an RRC and a specialty board. A board-eligible physician must pass the certification examination in a specialty to become boardcertified. See Appendix IV for certification requirements by specialty. A physician does not have to be board-eligible or board-certified to practice a specialty, but the incentives are considerable. Some RRCs see rates of certification of graduates as indicative of the quality of residency programs; physicians in those programs are encouraged to become certified. Some hospitals demand that physicians be board-eligible before they can admit patients, or have operating room privileges, or use such facilities as coronary care units. Also, professional fee reimbursement rates both vary with individual specialties and are higher for subspecialists as compared with physicians in prinmary care. And a new developinent is one insurance company's* reduction of malpractice insurance premiums for board-certified physicians. : 'Cooperative of American Physicians/Mutual Protection Trust The projected trend into the next century is for more physicians to become board-certified, probably to the extent that specialists in surgery, internal medicine, radiology and anesthesiology are now-which is about 78 percent. Another trend is toward recertification, intended to ensure a specialist's continued competence. This was first required by the American Board of Family Practice; six other boards now issue time-limited certificates and 12 more have approved plans for recertification. Control of GME in the Academic Health Center Influences on graduate medical education are expressed at a number of levels in the academic health center. Hospital directors often determine the number of residents needed to fulfill the hospital's needs, including staffing of such services as intensive care units. Thus, the director influences the experience and education of residents. The director also establishes controls, such as mandatory supervision of surgical residents by senior staff, to ensure quality care and to minimize malpractice exposure. Medical school deans sometimes exert influence to make the resident's experience meet the criteria for good education. Deans also are interested in the function of house staff in teaching medical students; the deans are concerned that the quantity and quality of residents in each service will maintain good teaching. Program directors in an academic health center have the basic responsibility for the quality of graduate medical education. Often a program director also is a medical school department chairman and chief of a service in the teaching hospital. 83-037 0-94-2 |