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1. The Future of Accreditation in Internal Medicine: A Resident’s Perspective

   • Benjamin J George, MD,
   • Ryan J Mattison, MD, University of North Carolina Hospitals

   Brooke Army Medical Center

   To the Editor:

   As current residents in internal medicine we are quite interested in the direction of accreditation for internal medicine programs. In fact, at a recent ACP-Council of Associates meeting in Philadelphia, PA, residency reform was discussed in great detail. The recent proposal from the RRC-IM to change residency program accreditation from a process-based evaluation to outcomes-based is a welcomed idea (1). From our perspective, there are several benefits to be realized by the proposed changes. Judging the clinical competence of residency program graduates is a clear, objective measure of whether the training program is doing its intended goal of providing the community with well-trained physicians. Using the existing six clinical competencies as a background for further accreditation allows programs to establish a base by which they can proceed under the new model.

   A more active, continually updated quality improvement process will mimic what is happening in other areas of medicine. The changes proposed by the RRC-IM will allow flexibility for program directors to be innovative and creative with residency education and prevent stagnation of graduate medical education. With ongoing internal assessments, residency programs will be able to change with the demands of society and adapt to problems more quickly. Over the years, these ideas can be shared among programs as evidence shows which educational aspects are effective and which ones are not. Also, by combining the requirements of the RRC with other rigorous site visits, i.e. JCAHO, this new model will eliminate the numerous redundancies faced by residency programs and their hospitals.

   While we agree with most of the aspects of the RRC’s proposed model, there are areas that need to be more adequately addressed. If we are going to continue to use clinical competencies as the basis for judging the effectiveness of training programs, then there needs to be validated clinical competency measures in place before the proposed accreditation system is started. Even by using current exceptional programs as the model, if there is no benchmark, what is it that is being measured? The RRC could propose that these ‘exceptional’ training programs do more controlled studies to prove the effectiveness of the clinical competencies and provide a true quality by which other programs can follow.

   The proposed internal evaluation coordinator has great potential to improve the training program more quickly and responsively than the current framework. However, even with proposed external salary support and/or ACGME certification, there may still be the appearance of a conflict-of-interest if a faculty member at an institution is primarily responsible for that institution's accreditation. There may be no perfect answer to this dilemma but perhaps one solution could be having the RRC allow a representative from one local hospital serve as the overseer for another hospital’s residency development.

   Benjamin George, MD Ryan Mattison, MD

   1. A New Model for Accreditation of Residency Programs in Internal Medicine

   Ann Intern Med 2004; 140: 902-909.

   Conflict of Interest:

   None declared

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   Published June 18, 2004