On Feb. 24, 2013, the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) announced their agreement to a memorandum of understanding that outlined a single graduate medical education system for residency and fellowship programs in the United States. Together, the organizations embarked upon a journey creating the infrastructure for a smooth transition to merge into a single system, which will transpire over the next five years.

As our allopathic and osteopathic emergency medicine programs undergo this merger together, there are current differences between the two regulatory bodies that may be especially significant to a subset of AOA emergency medicine residency programs: the community hospital–based osteopathic programs. Nearly three-quarters of the AOA EM programs are community based and have trained highly skilled board-certified physicians for many years. However, differences in core faculty requirements, as well as sponsoring institutional support, may threaten their stability and financial viability.

Faculty

The ACGME, unlike the AOA, requires protected time for core faculty. The current ACGME requirements state that core EM faculty cannot work in excess of 28 clinical hours per week on average. Further restrictions are placed on program directors (PDs), who are restricted to 20 clinical hours per week, and assistant or associate PDs, who are restricted to 24 clinical hours per week. The AOA requirements include protected time for their PDs but not for core faculty. Many of the community osteopathic programs pay their core faculty a small stipend, and many of those faculty members donate this stipend back to the school, serving as faculty for free. These osteopathic core faculty members earn their salary most often through their hourly paid clinical shift work. AOA community EM programs are understandably concerned about how to fund core faculty protected time, assuming incorporation of the limits on clinical hours with ACGME as the single accreditation body.

Additionally, ACGME programs previously could select their individual qualifying core faculty members from their rosters at large. The requirement included one core faculty member for every three residents, with the chair/chief, PD, and assistant or associate PDs as automatic core faculty members. However, recently, the definition of core faculty appears to have changed to automatically include all faculty on a given program’s roster who provide at least 15 hours of resident interaction per week on average. Although the most recent iteration of ACGME program requirements for graduate medical education in emergency medicine does not specifically address this qualification for inclusion as core faculty, it is clearly in practice.¹

AOA community emergency medicine programs are understandably concerned about how to fund core faculty protected time.

Currently, allopathic programs must provide an annual online update through ACGME’s Accreditation Data System (ADS). When entering/updating the faculty roster, the program is required to report the average number of resident interaction hours per week for all faculty who provide resident education and/or supervision. During the 2014 update, one of the authors noted that the ADS automatically assigned the status of core faculty to all staff meeting the 15 hours per week criteria mentioned above. The author’s program must provide a minimum of 12 core faculty for its 36 residents. The effect of the ADS automated process was to increase the core faculty count to 29 individual staff, representing 88 percent of all regularly scheduled staff. Also of note is that the PD is no longer considered part of the core faculty count for ADS reporting purposes and is therefore not one of the 29 mentioned above. This automated process compounds protected time challenges when considering the strict definition of core faculty and has been the subject of some discussion on the Council of Residency Directors listserv.

Community Hospital Setting

The ACGME clearly expects and holds the sponsoring institution accountable to provide a reasonable salary and protected time for core faculty. However, community-based osteopathic programs are concerned that their resources, often the local community hospitals, cannot afford to provide additional funding for their programs. Currently, an SAEM/ACEP work group is exploring alternative funding methods for graduate medical education spots, which could provide assistance. Some PDs and chairs suggest exploring the concept of clinical core faculty whose scholarly endeavors are truly centered at the bedside.

Along with required protected time for core faculty, the ACGME requires that they engage in a significant amount of scholarly activity, with specific requirements related to peer-review publications. In the community-based practice setting, this will be a change and a challenge related to the infrastructure of the sponsoring institutions, most frequently community hospitals.

Finally, current ACGME requirements include that the sponsoring institution for an EM program has a major educational commitment as evidenced by existing training programs in other major specialties to include internal medicine, general surgery, pediatrics, and obstetrics and gynecology. Once again, in a community hospital setting, the sponsoring institution may not have this supporting infrastructure in place.

As the ACGME/AOA merger advances, these significant differences will come to light. They are not insurmountable, and a thoughtful discussion aimed at a beneficial compromise for all programs will prevail. In the end, our uncompromising goal remains to provide the highest quality training and preservation of our hard-earned and staunchly supported EM programs.

Special thanks to Robert Hunter, DO, MPH, FACOEP, program director in emergency medicine at Grandview Medical Center in Dayton, Ohio; Thomas Matese, DO, FACOEP, program director in emergency medicine at St. Lucie Medical Center in Port St. Lucie, Florida; Mark Mitchell, DO, FACOEP, president of the American College of Osteopathic Emergency Physicians; and Sandy Schneider, MD, FACEP, ACEP director of emergency medicine practice and former chair of the University of Rochester department of emergency medicine.

Dr. Parker is chair of the ACEP Board of Directors and clinical assistant professor at Texas Tech University in El Paso. Dr. Robinson is vice chair and program director in the department of emergency medicine at John Peter Smith Hospital in Fort Worth, Texas, and past president of the Texas College of Emergency Physicians.

Reference

1. ACGME program requirements for graduate medical education in emergency medicine. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/110_emergency_medicine_07012013.pdf. Accessed April 10, 2015.