Medical Accreditation in the United States: What For?

Accreditation involves the establishment of criteria and the enforcement of those criteria to make sure that programs, schools, or other organizations have met all the official requirements of academic excellence, curriculum, facilities, and other aspects promulgated by the accrediting agency. In an era when the public wants to be ensured of quality, the “accredited” label is meaningful to conscientious consumers. Accreditation activities abound in the medical arena, and one could realistically ask, “What for?” Although accreditation and certification have similar meanings in the medical context, the functional processes differ in that accreditation usually applies to the measurement of quality of educational programs and certification applies to the qualifying of individuals who have completed those programs. The mission statement of the American Board of Plastic Surgery states that its goal is to “…maintain high standards for the education, examination, certification and maintenance of certification of plastic surgeons.…”1 Except for individual cases in which educational backgrounds are reviewed, the “education” part of that statement is delegated to other groups (Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada) who accredit the programs in which individuals desiring to be certified by the board are trained. HISTORY Abraham Flexner, along with William Welch (the founding dean at Johns Hopkins), William Osler, and Frederick Gates (an adviser to John D. Rockefeller), formed the “Hopkins Circle,” a group to which can be attributed the scientific base on which medical education in the United States is founded today. After spending time as an educator, surveying university education in Europe and writing a book—The American College—Flexner was asked by the Carnegie Foundation to survey and provide a report of medical education in the United States.2 His findings were published in 19103 and, as a result, approximately one-third of all medical schools in the country were closed. The basis for this action was the lack of facilities, finances, laboratories, admission standards, and other factors, and these findings were supported by the states in which they were located, in addition to the Council of Medical Education of the American Medical Association and the Association of American Medical Colleges. This report established standards on which the quality of medical education could be judged—the essence of the principles of accreditation. Residency training began around the turn of the century, and the Clinical Congress of Surgeons of North America, an annual meeting in Chicago that also started in 1910, appointed the “Committee on the Standardization of Surgery” in 1912. This turned out to be the organizing committee of the American College of Surgeons. Its charge was to establish minimum standard requirements for the training of surgeons. This training was intended to supplement the regular medical degree.4 Dr. Franklin Martin, the general secretary of the American College of Surgeons, stated in 1916 that the College should “set about the work” of establishing standards for surgical training. A committee on standards was established, and this led to the fellowship requirements that involved specific training in a surgical specialty, particularly focused on the hospitals in which the training was to take place. The Committee on Undergraduate, Graduate and Postgraduate Teaching of Surgery and the Surgical Specialties (1930) and later, the Committee for Graduate Training for Surgery (1934), began to refine the parameters of appropriate surgical training. In 1937, the College began the evaluation and approval of residency programs, with field staff visiting hospitals and reviewing them. At the same time, the American Medical Association had a program for reviewing hospitals, and the nascent specialty boards had begun to function and develop requirements for their examinations. The three groups convened in 1950 and, after much “tedious and sometimes spirited negotiations,” the Conference Committee on Graduate Training in Surgery was formed in 1953.4 Surgical subspecialty committees followed, beginning in 1955. Although interest in a tripartite committee in plastic surgery was initiated in 1951, the Residency Review Committee (the new name for these committees) for Plastic Surgery was not officially organized until October 18, 1956. It has met at least twice yearly since that time. Currently, the Residency Review Committee for Plastic Surgery consists of 12 members, three each appointed by the American Medical Association, the American College of Surgeons, and the American Board of Plastic Surgery, one from the American Osteopathic Association, a resident member, and public member. In 1972, an overarching accreditation system was envisioned by Dr. C. H. William Ruhe, the director of the Division of Medical Education of the American Medical Association. After many meetings and much deliberation, accreditation organizations were created for residency education (the Liaison Committee for Graduate Medical Education), continuing medical education (the Liaison Committee for Continuing Medical Education), and allied health education (the Committee for Allied Health Education Accreditation). These were patterned after the Liaison Committee for Medical Education, which had been accrediting medical schools since 1942.5 They were placed under the umbrella of the Coordinating Council on Medical Education, whose task was to coordinate the medical education activities of all of medicine. The parent organizations of each body obviously varied, and the current construct of each of the physician accrediting groups is listed in Table 1. In the case of graduate medical education, the existing Residency Review Committee structure was incorporated under the Liaison Committee for Graduate Medical Education umbrella.Table 1.: Current Composition of Medical Education Accrediting AgenciesAs might have been expected, the herculean task assigned to the Coordinating Council on Medical Education proved very cumbersome, particularly because decision-making had to be circulated among all the parent organizations. In 1981, the Coordinating Council on Medical Education was dissolved and the others were reorganized into the Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and the Commission on Accreditation of Allied Health Education Programs. In graduate medical education, the Accreditation Council for Graduate Medical Education establishes the principles and requirements of residency programs in general, and the 28 Residency Review Committees are responsible for developing specific requirements and applying them to individual training programs in their specialty. There are also an Institutional Review Committee and a Transitional Year Committee. In 2015, with the incorporation of osteopathic programs into the accreditation process, the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine were added to the parent organizations of the Accreditation Council for Graduate Medical Education. THE PURPOSE OF ACCREDITATION The motivations for these accreditation processes are threefold. The first is a sincere desire to maintain and improve the quality of medical education so that medical students, residents, and practicing physicians receive good value for their expenditure of time, money, and energy. The second is to assure the public that the products of these educational processes will serve them well. The third was true in the early 1970s, and is still true today, and is this: if the medical community does not do the accrediting themselves, someone else will, namely, the government. At the present time, the government has been satisfied with the existing arrangement and has chosen to leave medical accreditation in the private sector. Thus, does this elaborate and expensive system of accreditation accomplish its purposes? Having answered the third point above, a brief statement regarding the other two motivations will possibly support my contention that the answer to the question is yes. Although adhering to the many specifics of accreditation requirements is unquestionably burdensome, it does serve the purpose of ensuring quality. In addition to the organizations listed above that accredit medical education, multiple other accrediting organizations oversee other parts of the health care enterprise.6 The Joint Commission (hospitals, nursing centers, home care agencies, laboratories), the Accreditation Association for Ambulatory Health Care (ambulatory surgery centers, medical and dental group practices, managed care organizations), and the American Association for Accreditation of Ambulatory Surgery Facilities (ambulatory surgery facilities) have all functioned as accrediting agencies for more than 30 years. Others have not stood the test of time.7 One characteristic common to all the groups mentioned previously is that they have multiple stakeholders as noted in Table 1. It is this cross-fertilization of ideas, perspectives, and insights that give them their imprimatur in the respective areas. One example of this occurs in the Accreditation Council for Graduate Medical Education when a specialty wants to have a subspecialty fellowship approved. All other specialties represented in the Accreditation Council for Graduate Medical Education have the opportunity to have input into the approval process. Conversely, some organizations who are not accredited by any of the multiple stakeholder groups can approve new programs or change requirements with no external input or oversight. All the requirements of accreditation for the listed medical organizations and education groups have been vetted through a long process of discussion with other interested parties and, in many cases, have been scientifically examined or are the result of decades of experience. The Milestones Project is another example in which years of discussion, beta testing, and now follow-up testing is providing an excellent method of resident evaluation.8 The process also allows for flexibility and innovation to accommodate changes within the health care environment.9,10 The second motivation of assuring the public that it will be well served by these processes is perhaps a secondary objective. The primary “customer” of the accrediting agencies is the constituency they serve. For the Liaison Committee for Medical Education, it is the medical schools and medical students. For the Accreditation Council for Graduate Medical Education and the Residency Review Committee for Plastic Surgery, it is the training programs and their residents. The American Council of Academic Plastic Surgeons also serves the training programs and residents by providing a forum for the growth of program directors. For the Accreditation Council for Continuing Medical Education, it is the practicing physicians. However, it is the promulgation and enforcement of standards that creates an environment where the best education and training can take place. This does not always guarantee the physician will deliver compassionate care, but it does guarantee that the physician has been involved in a program subject to rigorous standards.11 It is the American Board of Medical Specialties that mentions a primary obligation to the public (as does the American Board of Plastic Surgery) in its role of certifying individuals as they graduate from training programs and then move through their practice career.12,13 It is this synergy between the Residency Review Committees and the boards,14 along with specialty societies, that has proved so effective in providing the public with high-quality physicians and has assured the government that the medical community can largely regulate itself. So, how can we answer the question, “What for?” There is an entire world of unregulated, unaccredited medical training outside of the boundaries of the accrediting agencies discussed above. Some of these offerings may be of very high quality and very effective. Many others, however, suffer from minimal oversight or no oversight at all. Unaccredited programs and nonvetted “boards” abound. Plastic surgeons, in particular, are acutely aware of these issues, as physicians and nonphysicians market their wares, having had no American Board of Plastic Surgery certification or Accreditation Council for Graduate Medical Education–approved training along the way. It is indeed a frustration that the legal system allows this type of activity to proliferate, but we must always take the “high road” as we maneuver in that system. The standards for the accreditation process have been developed over decades, have stood the test of time, and continue to be modified as new techniques and information become available. Therefore, we must be careful of aligning ourselves with individuals or organizations that have not met the standards we have set for our specialty and that have served medicine and the public well. Otherwise, the specialty of plastic surgery will be tarnished and the exemplary quality of care we enjoy, envisioned over 100 years ago, will be compromised.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.