The Program Director Guide to the Common Program Requirements (Fellowship and One-Year Fellowship)

• Graduating residents and fellows who strive for continuous mastery and altruistic professionalism throughout their careers, placing the needs of patients and their communities first. 4 * The Quadruple Aim simultaneously improves patient experience of care, population health, and health care provider work life, while lowering per capita cost. ACGME Values • Honesty and Integrity • Accountability and Transparency • Equity and Fairness • Diversity and Inclusion • Excellence and Innovation • Stewardship and Service • Leadership and Collaboration • Engagement of Stakeholders 5 Program Director Guide to the Common Program Requirements Contents (Fellowship and One-Year Fellowship) Introduction ………………………………………………………………………….. 9 Int.A. Introduction ……………………………………………………………………... 9 Int.B. Definition of Specialty …………………………………………………………. 12 Int.C. Length of Educational Program ……………………………………………… 14 I.Oversight ……………………………………………………………………………. 16 I.A. Sponsoring Institution ……………………………………………………………. 16 I.B.1 Participating Sites ……………………………………………………………… 18 I.B.2.a) and I.B.3. PLAs with AAMC Template ……………………………………. 23 I.C. and V.C.1.c) to V.C.5.c) …………………………………………………………. 28 I.D.1. to 4. Includes Lactation ………………………………………………………... 32 I.E. and I.E.1. Presence of Other Learners ………………………………………... 37 II. Personnel ………………………………………………………………………….. 39 II.A.1.a) and II.A.1.b) Program Director Appointment ……………………………... 39 II.A.2. Program Director Support with Definition of Administrative Time …. 42 II.A.3. and II.A.3.a) to d) Qualifications of the Program Director ………………... 48 II.A.4. Program Director ……………………………………………………………… 50 II.A.4.a).(1) to (7) Program Director Responsibilities ………………………… 52 II.A.4.a).(8) Program Director Responsibilities Submit Accurate Information ….. 62 II.A.4.a).(9) Fellowship Board Eligibility and Sample Letter to Applicants ……. 75 II.A.4.a).(10) to (13).(a); II.A.4.a).(10) to (13).(a) Grievances, Due Process, Non-Discrimination, Restrictive Covenant ….. 78 II.A.4.a).(14) and (15) Provide Verification and Milestones not High Stakes ……………... 81 6 II.A.4.a).(16) Program Director must Submit Accurate Information Table ……… 85 II.B.1. to 2. Number Sufficient Time Faculty Development ……………………… 88 II.B.3. Faculty Qualifications …………………………………………………………. 92 II.B.4. Core Faculty …………………………………………………………………… 95 II.C. and II.D. Coordinator and Other Personnel ………………………………….. 97 III. Fellow Appointments …………………………………………………………… 100 III.A. Fellow Appointments, Eligibility Criteria ……………………………………… 100 III.B. and III.C. Complement Increase and Fellow Transfers ……………………... 117 IV. Educational Program …………………………………………………………… 120 IV. and IV.A.1. to 5. Educational Program …………………………………………. 120 IV.B. Competencies ………………………………………………………………….. 132 IV.B.a.1.a) to g) Competencies Professionalism ………………………………….. 136 IV.B.1.b) Competencies Patient Care and Procedural Skills ……………………... 142 IV.B.1.c) Competencies Medical Knowledge ……………………………………… 144 IV.B.1.d) Competencies Practice-based Learning and Improvement …………… 146 IV.B.1.e) Competencies Interpersonal and Communication Skills ……………… 150 IV.B.1.f) Competencies Systems-based Practice …………………………………. 155 IV.C. Curriculum Organization and Resident Experiences ……………………….. 158 IV.C.2. Pain Management including Addiction ……………………………………... 160 IV.D.1 to IV.D.3 Faculty and Fellow Scholarly Activity ……………………………. 167 IV.E. Independent Practice Option Fellowship ……………………………………. 176 V. Evaluation …………………………………………………………………………. 178 V. and V.A. Evaluation and Fellow Evaluation ……………………………………... 178 V.A.1.d).(2) Individualized Learning Plan ………………………………………….. 184 V.A.1.d).(3) Plans for Failing to Progress, Remediation, Etc. …………………… 190 7 V.A.1.e) and f) Summative Evaluation and Evaluations Accessible to Fellows … 197 V.A.2. and V.A.2.a) and V.A.2.a).(1) Final Evaluation includes Not to Use Milestones for High Stakes ……………... 199 V.A.3.b).(1) to (3) Clinical Competency Committee ……………………………….. 202 V.B.1. Faculty Evaluation includes Confidentiality ………………………………... 204 V.C. and V.C.1.a) to e) Program Evaluation and Improvement …………………. 210 V.C.2. and V.C.2.a) Self-Study ……………………………………………………… 220 V.C.3.a) to f) with Background and Intent Board Certification …………………… 224 VI. The Learning and Working Environment …………………………………… 228 VI.A.1.a) Patient Safety ……………………………………………………………… 228 VI.A.1.b) Health Care Quality ………………………………………………………... 235 VI.A.2. Supervision and Accountability ……………………………………………... 242 VI.B. Professionalism …………………………………………………………………. 250 VI.C. Well-Being ……………………………………………………………………… 258 VI.D. Fatigue Mitigation ……………………………………………………………… 263 VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ……………... 267 VI.F. Clinical Experience and Education …………………………………………… 272 Appendix ……………………………………………………………………………….. 285 8 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement Background and Intent: These fellowship requirements reflect the fact that these learners have already completed the first phase of graduate medical education. Thus, this document is intended to explain the differences. Introduction Int.A. Fellowship is advanced graduate medical education beyond a core residency program for physicians who desire to enter more specialized practice. Fellowship-trained physicians serve the public by providing subspecialty care, which may also include core medical care, acting as a community resource for expertise in their field, creating and integrating new knowledge into practice, and educating future generations of physicians. Graduate medical education values the strength that a diverse group of physicians brings to medical care. Fellows who have completed residency are able to practice independently in their core specialty. The prior medical experience and expertise of fellows distinguish them from physicians entering into residency training. The fellow’s care of patients within the subspecialty is undertaken with appropriate faculty supervision and conditional independence. Faculty members serve as role models of excellence, compassion, professionalism, and scholarship. The fellow develops deep medical knowledge, patient care skills, and expertise applicable to their focused area of practice. Fellowship is an intensive program of subspecialty clinical and didactic education that focuses on the multidisciplinary care of patients. Fellowship education is often physically, emotionally, and intellectually demanding, and occurs in a variety of clinical learning environments committed to graduate medical education and the well-being of patients, residents, fellows, faculty members, students, and all members of the health care team. In addition to clinical education, many fellowship programs advance fellows’ skills as physician-scientists. While the ability to create new knowledge within medicine is not exclusive to fellowship-educated physicians, the fellowship experience expands a physician’s abilities to pursue hypothesis-driven scientific inquiry that results in contributions to the medical literature and patient care. Beyond the clinical subspecialty 9 expertise achieved, fellows develop mentored relationships built on an infrastructure that promotes collaborative research. 10 GUIDANCE Introduction text is not requirement language. Int.A. provides a philosophic statement that embodies the meaning and purpose of graduate medical education. It describes why graduate medical education is important and why programs must ensure that fellows are provided with the best education possible. 11 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement: Int.B. Definition of Subspecialty [The Review Committee must further specify] 12 GUIDANCE For the definition of a particular subspecialty, refer to the current subspecialty-specific Program Requirements, which can be found on the Program Requirements and FAQs and Applications page of the applicable specialty section on the ACGME website. For example, this link takes you to the Program Requirements and FAQs and Applications page for Orthopaedic Surgery, from which you can access the Program Requirements for all subspecialties of orthopaedic surgery. 13 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement Int.C. Length of educational program [The Review Committee must further specify] 14 GUIDELINES For the length of the educational program for a particular subspecialty, refer to the current subspecialty-specific Program Requirements, which can be found on the Program Requirements and FAQs and Applications page of the specialty’s section on the ACGME website. For example, this link takes you to the Program Requirements and FAQs and Applications page for Orthopaedic Surgery, from which you can access the Program Requirements for all subspecialties of orthopaedic surgery. 15 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide background and Intent Common Program Requirement: I. Oversight I.A. Sponsoring Institution The Sponsoring Institution is the organization or entity that assumes the ultimate financial and academic responsibility for a program of graduate medical education, consistent with the ACGME Institutional Requirements. When the Sponsoring Institution is not a rotation site for the program, the most commonly utilized site of clinical activity for the program is the primary clinical site. Background and Intent: Participating sites will reflect the healthcare needs of the community and the educational needs of the fellows. A wide variety of organizations may provide a robust educational experience and, thus, Sponsoring Institutions and participating sites may encompass inpatient and outpatient settings including, but not limited to a university, a medical school, a teaching hospital, a nursing home, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, an educational consortium, a teaching health center, a physician group practice, federally qualified health center, or an educational foundation. I.A.1. The program must be sponsored by one ACGME-accredited Sponsoring Institution. (Core) 16 GUIDANCE ACGME Common Program Requirement I.A.1. corresponds with ACGME Institutional Requirement I.A.1.: “Residency and fellowship programs accredited by the [ACGME] must function under the authority and oversight of one Sponsoring Institution. Oversight of resident/fellow assignments and of the quality of the learning and working environment by the Sponsoring Institution extends to all participating sites.” Sponsorship of a program includes responsibility for oversight of the Sponsoring Institution’s and all accredited programs’ compliance with the applicable ACGME requirements, and the assurance of the resources necessary for graduate medical education. The ACGME Board of Directors delegates authority for accrediting Sponsoring Institutions to the Institutional Review Committee. The ACGME’s primary point of contact with each Sponsoring Institution is the designated institutional official (DIO). For more information about Sponsoring Institutions, refer to the ACGME Institutional Requirements and Frequently Asked Questions for institutional review. 17 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement I.B. Participating Sites A participating site is an organization providing educational experiences or educational assignments/rotations for fellows I.B.1. The program, with approval of its Sponsoring Institution, must designate a primary clinical site. (Core) [The Review Committee may specify which other specialties/programs must be present at the primary clinical site and/or the expected relationship with a core program in the discipline] I.B.2. There must be a program letter of agreement (PLA) between the program and each participating site that governs the relationship between the program and the participating site providing a required assignment. (Core) 18 GUIDANCE Primary Clinical Site Designations and Sponsoring Institution Approval The Common Program Requirements define a program’s primary clinical site as “the most commonly utilized site of clinical activity for the program.” In a program’s Accreditation Data System (ADS) profile, the primary clinical site can be found in the “Sites” tab (marked as “Primary” under “Participating Site Information”). In applications for ACGME accreditation, programs are directed to identify one of their participating sites as the primary clinical site. A Sponsoring Institution’s approval of the primary clinical site designation is implicit in submissions of participating site information in ADS. The ACGME does not currently provide a standardized format for documenting institutional approval of these designations. Refer to the subspecialty-specific Program Requirements for additional information. All rotation sites can be entered, but only required sites appear. NOTE that the ADS format may change to reflect updates to the Common Program Requirements. Instructions: The following Institutions have been selected as having an affiliation with your Sponsoring Institution. From this list, programs will choose the individual rotation sites (to comply with common program requirements) that routinely provide an educational experience, required for all residents of one-month full time equivalent (FTE) or more. Some subspecialties have a varied interpretation of this requirement. The DIO/GMEC must ensure that programs have established program letters of agreement for all required rotations of one month or more. To remove an institution/entity from this list, click on the "X" next to that institution's name. To remove the Sponsoring Institution as a place of rotation, contact ads@acgme.org. The definition of a participating site as it appears in ADS: An organization (or entity) providing educational experiences or educational assignments/rotations for residents/fellows. Examples of sites include inpatient and outpatient settings including, but not limited to university, a medical school, a teaching hospital which includes its ambulatory clinics and related facilities, a private medical practice or group practice, a nursing home, a school of public health, a health department, a federally qualified health center, a public health agency, an organized health care delivery system, a health maintenance organization (HMO), a medical examiner’s office, an educational consortium, a teaching health center, federally qualified health center, or an educational foundation. There may be a need to indicate the site as “clinical” in rare occasions. A clinical site exists when the sponsor of a program is in a different site (location) than the PRIMARY clinical site out of which the program operates. 19 Notes: 1. The table requesting information for the primary clinical site is followed by tables that allow you to enter information for other participating sites. 2. Each of the site information tables is followed by a request for information regarding Program Letters of Agreement (PLAs) and PLA components for the particular site. (See section on PLA: Requirements I.B.2.a) and I.B.3.) 3. Additional information requested includes “Date Added to ADS as Rotation Site.” 4. Once information is entered and saved, the program can print a report of the information. Below is an example of a screen for data entry for participating site information in ADS: 20 Identifying the Most Commonly Utilized Participating Site A program should follow its Sponsoring Institution’s methods for identifying the primary clinical site. Typically, the “most commonly utilized” participating site is that which has the highest count of fellow full-time equivalents in a program over an academic year, assuming a full and evenly distributed fellow complement. There are different sources of information that can be used to determine which participating site is “most commonly utilized” by a program. For fellowship programs that provide education in hospital settings and receive reimbursement from the Centers for Medicare and Medicaid for direct graduate medical education and indirect medical education, hospital cost reports may help to quantify utilization. It is also possible to use a program’s block diagram to estimate distribution of fellow education among the participating sites. Avoiding Common Errors in the ADS Annual Update: Creating an Effective Block Schedule Video Total Viewing Time: 9 minutes Click on the picture above to be directed to the video Participating sites may be an inpatient or outpatient setting. Examples of participating sites include: a. Hospitals, including outpatient clinics and related facilities b. Private practice c. Nursing home 21 d. Health department e. Federally qualified health center f. Public health agency g. An organized health care delivery system h. Health maintenance organization (HMO) i. Medical Examiner’s office Subspecialty-Specific Requirements for Primary Clinical Sites Whatever method is used to calculate utilization, a program must also ensure the presence of other specialties and/or programs at the primary clinical site, as required in the specialty- and subspecialty-specific Program Requirements. Questions about specialty- and subspecialty-specific requirements or expectations for the primary clinical site should be directed to staff members of the relevant Review Committee. 22 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement I.B. Participating Sites I.B.2. There must be a program letter of agreement (PLA) between the program and each participating site that governs the relationship between the program and the participating site providing a required assignment. (Core) I.B.2.a) The PLA must: I.B.2.a).(1) be renewed at least every 10 years; and, (Core) I.B.2.a).(2) be approved by the designated institutional official (DIO) (Core) I.B.3. The program must monitor the clinical learning and working environment at all participating sites. (Core) I.B.3.a) At each participating site there must be one faculty member, designated by the program director, who is accountable for fellow education at that site, in collaboration with the program director. (Core) Background and Intent: While all fellowship programs must be sponsored by a single ACGME- accredited Sponsoring Institution, many programs will utilize other clinical settings to provide required or elective training experiences. At times it is appropriate to utilize community sites that are not owned by or affiliated with the Sponsoring Institution. Some of these sites may be remote for geographic, transportation, or communication issues. When utilizing such sites, the program must designate a faculty member responsible for ensuring the quality of the educational experience. In some circumstances, the person charged with this responsibility may not be physically present at the site, but remains responsible for fellow education occurring at the site. The requirements under I.B.3. are intended to ensure that this will be the case. Suggested elements to be considered in PLAs will be found in the ACGME Program Director’s Guide to the Common Program Requirements. These include: • Identifying the faculty members who will assume educational and supervisory responsibility for fellows • Specifying the responsibilities for teaching, supervision, and formal evaluation of fellows • Specifying the duration and content of the educational experience • Stating the policies and procedures that will govern fellow education during the Assignment 23 I.B.4 The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all fellows, of one month full time equivalent (FTE) or more through the ACGME’s Accreditation Data System (ADS). (Core) [The Review Committee may further specify] 24 GUIDANCE The program letter of agreement (PLA) is a written document that addresses graduate medical education responsibilities between a program and a site other than the Sponsoring Institution at which fellows have required educational experiences. 1. Program directors are responsible for PLAs, and designated institutional officials (DIOs) are required to review and approve all PLAs. 2. PLAs are not required for sites used only for elective rotations. 3. PLAs are between a program and the participating site and include all rotations taking place at that participating site. The purpose of a PLA is to ensure a shared understanding of expectations for the educational experience, the nature of the experience, and the responsibilities of the participating site. 1. The program director must add all participating sites routinely providing an educational experience of one month or more into the Accreditation Data System (ADS). If the program director does not see the site listed as an option in ADS, contact the DIO, as the site may need to be added into ADS by the Sponsoring Institution. Adding participating sites that provide elective experiences and/or those less than one month in length in ADS is optional. 2. If fellows are no longer rotating to a site, the program director must remove the site in ADS. 3. Once a site is added or removed in ADS, the Review Committee receives the information for review. Suggested elements of a PLA: 1. Duration of the educational experience(s) 2. Content of the educational experience(s) (e.g., rotation names, educational objectives) 3. Site director name and title 4. Faculty members who will assume educational and supervisory responsibility for fellows during each rotation at the site (faculty members can be identified by individual name or as a group) 5. Specific responsibilities of the supervising faculty members for teaching, supervision, and formal evaluation of fellows 6. Policies and procedures that will govern fellow education during the assignment 7. Considerations for travel time and distance to the participating site, and when the program should consider providing the fellows with accommodations proximal to the participating site 8. Description of expectations regarding fellow participation in didactic activities during rotations at the participating site What does the PLA information look like in ADS? 25 Examples of rotations that require a PLA: 1. One-month rotation in a pediatric inpatient unit in a children’s hospital required of all fellows by a family medicine program 2. One-month rotation in rheumatology required by an internal medicine program to take place at a site that is not the Sponsoring Institution 3. Required two-month rotation in an emergency department with a Level 1 trauma center at a site that is not the Sponsoring Institution 4. Required osteopathic neuromusculoskeletal medicine inpatient rotation 5. Geriatric continuity of care experience in a long-term care facility throughout the academic year required for all family medicine fellows 6. Two-week retina rotation with a community physician required for all ophthalmology fellows Potential Citations: 26 1. Failure to have a fully executed PLA for each site outside of the Sponsoring Institution to which fellows rotate for a required educational experience 2. Failure to have DIO approval of the PLA 3. Failure to renew a PLA every 10 years 4. Incorrect/incomplete participating site information in ADS 27 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide background and Intent Common Program Requirement: Note: Because this requirement addresses the need for recruitment and retention to be consistent with institutional and program missions, which likely already exist, it is not anticipated that programs will require an extended period of time for implementation. I.C. The program, in partnership with its Sponsoring Institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of fellows, fellows (if present), faculty members, senior administrative staff members, and other relevant members of its academic community. (Core) Background and Intent: It is expected that the Sponsoring Institution has, and programs implement, policies and procedures related to recruitment and retention of minorities underrepresented in medicine and medical leadership in accordance with the Sponsoring Institution’s mission and aims. The program’s annual evaluation must include an assessment of the program’s efforts to recruit and retain a diverse workforce, as noted in V.C.1.c).(5).(c). V.C. Program Evaluation and Improvement V.C.1.c).(5).(c). workforce diversity; (Core) 28 GUIDANCE Many Sponsoring Institutions may have defined mission statements pertaining to diversity. While most, if not all institutions have policies regarding diversity, it is understood that these will serve as a starting point, and there are aspects of this requirement that could take considerable time to produce quantifiable results, so the initial emphasis will be on process, not numerical outcomes. The definition of diversity is intended to parallel that of the Association of American Medical Colleges’ philosophy on Underrepresented in Medicine, which permits flexibility in defining the target groups for diversity based on the service demographic of the program that is underrepresented relative to the workforce for a given role. Although Common Program Requirement I.C. states that programs must engage in mission-driven, ongoing, systematic efforts to recruit and retain individuals of diverse backgrounds as residents and fellows, if present, it is important to consider the ability to alter the number of such individuals appreciably will require years of effort to expand the pool of diverse graduate medical education (GME) applicants. Most of this will be cooperative efforts among programs within institutions, or even within cities, and within the specialty itself. Each program is asked to present the demographic information for all GME learners on the Fellow Roster in the Accreditation Data System (ADS). This information will provide important baseline data on the number of individuals as a function of race, ethnicity, and gender. With time, as efforts to enhance the pool of diverse learners improves, ACGME assessment may shift to include effort in terms of the actual increase in the number of diverse learners. To assess meaningful change, it is essential to track these numbers annually to document continued progress. Since the Fellow Roster is a secondary report of demographics, it is important that the best data possible be entered. The gold standard for obtaining the race and ethnicity of each fellow is for the program staff to ask directly how each fellow would choose to be represented. A less optimal way of obtaining this information is to import the race, ethnicity, and gender information for each fellow from the electronic application used at the time of fellowship selection. This is primary data supplied by the fellows themselves and simple transfer of this information is perhaps the most efficient way of supplying the ACGME with it. In 2020, the ACGME introduced the Resident/Fellow Portal, accessible via ADS. The Resident/Fellow Portal is a tool that allows residents/fellows t o obtain access to the following: • Profile information (this includes the ability to edit some information) • Their own GME history • Program-level aggregated Resident/Fellow Survey Reports • Milestone evaluations Residents/fellows in a program that uses the Case Log System already have access to the Resident/Fellow Portal by default; residents/fellows in programs that do not use the Case Log System must opt in and create an account to access the Resident/Fellow Portal. 29 Demographic information for each fellow, populated through the Association of American Medical Colleges (AAMC), is now available in the ACGME Resident/Fellow Portal thanks to an agreement between the organizations. Fellows are able to update their own demographic information if it changes during the course of their fellowship program. As there is not currently universal use of the Resident/Fellow Portal, the ACGME will continue to ask that demographic information be included in the program’s Fellow Roster in ADS. For Academic Year 2021-2022, the demographic categories used by the ACGME reflect races as: White; Black or African American; Asian; Native Hawaiian/Pacific Islander; and American Indian/Alaska Native. Ethnicity categories are reflected as: Hispanic, Latino or of Spanish originand “other/unknown.” Program representatives entering this information for their program’s fellows will select one of these categories for each fellow on the Fellow Roster. There are two additional categories: Other and Unknown. The system currently does not provide the option to select multiple races. If a fellow prefers to identify as multiracial to the exclusion of a single race choice, “Other” is the suggested category. If a fellow has indicated a preference not to answer, or if any fellows truly do not know how to identify their race/ethnicity (e.g., a fellow who was adopted or who is the child of an adopted individual), or if the program is unable to obtain any information from the any fellows pertaining to their demographics after making reasonable attempts to obtain it), only then should the “Unknown” category be selected. The ACGME asks that programs make every effort to obtain this information and report it as accurately as possible, because the program director will only be aware of the program’s diversity success or challenge if it is obtained and measured over time. For gender, the ACGME currently offers three options for programs to report on the fellow roster: Male, Female, or Not Reported. For individuals who identify as male, select “Male,” for those who identify as female, select “Female.” For those who choose not to identify as either (e.g., individuals who identify as non-binary, who are transgender, or who prefer not to disclose) select “Not Reported.” Again, every effort should be made to accurately record this information on the Fellow Roster in ADS as it will be tracked for baseline establishment and serve as a metric to assess positive change in program and GME diversity over time. To further clarify the information provided in the Background and Intent section for this requirement, it is expected that programs, in partnership with their Sponsoring Institution, have and implement policies and procedures related to recruitment and retention of individuals underrepresented in medicine and medical leadership in accordance with the Sponsoring Institution’s mission and aims. The population of individuals considered underrepresented in medicine will include racial and ethnic minority representation that reflects the program’s service area, but may also include others the program deems underrepresented in medicine in the service area or in the 30 discipline in general. A core element of a program’s annual evaluation, as noted in V.C.1.c).(5).(c) on workforce diversity, should include an assessment of the demographic population in the area served by the program and its efforts to recruit and retain a diverse workforce of individuals who are underrepresented in medicine reflective of the service area population in the roles clarified in I.C. (fellows, fellows, faculty members, senior GME administrative staff members, and other relevant members of its academic community). The ACGME is interested in the diversity of the physician workforce because it is essential to addressing health care access and health equity. The ACGME Board of Directors formed a Planning Committee on Diversity in Graduate Medical Education, which first met in 2018, reviewed an extensive bibliography (Appendix 1), and held discussions that culminated in the observations summarized in Appendix 1. The ACGME has embarked on a pathway to convene the GME community around creation of a new initiative, ACGME Equity Matters, to assist programs in enhancing diversity, equity, and inclusion locally and across GME. Output of this initiative will include a toolkit of approaches from the GME community that address many of the barriers diverse individuals face in the GME environment. Some ideas employed by the most inclusive programs have already emerged and include: having a chief diversity officer position; creating and supporting a diversity committee; and actively engaging minority individuals in the learning environment to help eliminate barriers to success in recruitment and retention. Finally, the AAMC’s new tool, the Diversity Engagement Survey (https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/engagement- survey), assesses the climate in a program with respect to diversity. 31 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement I.D Resources I.D.1 The program, in partnership with its Sponsoring Institution, must ensure the availability of adequate resources for fellow education. (Core) [The Review Committee must further specify] I.D.2. The program, in partnership with its Sponsoring Institution, must ensure healthy and safe learning and working environments that promote fellow well-being and provide for: (Core) I.D.2.a) access to food while on duty; (Core) I.D.2.b) safe, quiet, clean, and private sleep/rest facilities available and accessible for residents with proximity appropriate for safe patient care; (Core) Background and Intent: Care of patients within a hospital or health system occurs continually through the day and night. Such care requires that fellows function at their peak abilities, which requires the work environment to provide them with the ability to meet their basic needs within proximity of their clinical responsibilities. Access to food and rest are examples of these basic needs, which must be met while fellows are working. Fellows should have access to refrigeration where food may be stored. Food should be available when fellows are required to be in the hospital overnight. Rest facilities are necessary, even when overnight call is not required, to accommodate the fatigued fellow. I.D.2.c) clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care; (Core) Background and Intent: Sites must provide private and clean locations where fellows may lactate and store the milk within a refrigerator. These locations should be in close proximity to clinical responsibilities. It would be helpful to have additional support within these locations that may assist the fellow with the continued care of patients, 32 such as a computer and a phone. While space is important, the time required for lactation is also critical for the well-being of the fellow and the fellow's family, as outlined in VI.C.1.d).(1). I.D.2.d) security and safety measures appropriate to the participating site; and, (Core) *I.D.2.e) accommodations for residents with disabilities consistent with the Sponsoring Institution’s policy. (Core) (Subject to citation July 1, 2020) I.D.3. Fellows must have ready access to specialty-specific and other appropriate reference material in print or electronic format. This must include access to electronic medical literature databases with full text capabilities. (Core) I.D.4. The program’s educational and clinical resources must be adequate to support the number of fellows appointed to the program. (Core) [The Review Committee may further specify] VI.C.1.d).(1) Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours. (Core) Background and Intent: The intent of this requirement is to ensure that residents have the opportunity to access medical and dental care, including mental health care, at times that are appropriate to their individual circumstances. Residents must be provided with time away from the program as needed to access care, including appointments scheduled during their working hours. 33 GUIDANCE Access to Food, Sleep/Rest Facilities, and Lactation Facilities Programs are expected to partner with their Sponsoring Institution to ensure fellows have adequate access to food, sleep/rest facilities, and lactation facilities, and to ensure appropriate safety and security measures are in place at all participating sites. Interpretations of the requirements for space may depend on the attributes of a participating site and the needs of fellows when assigned to that site. Sleep/rest facilities and lactation facilities must be secure, clean, and free of vermin. At different participating sites, there may be differences in how fellows perceive features of sleep/rest facilities (e.g., gender-based use, bunking). There may also be differing expectations for sleep/rest facilities based on the type of assignment (e.g., overnight call, outpatient clinic). Because of site-, program-, and fellow-specific factors, the ACGME does not dictate specifications for the physical space of sleep/rest and lactation facilities beyond the qualities indicated in the requirements and the associated guidance in the associated Background and Intent section. When assessing whether sleep/rest and lactation facilities are substantially compliant with the requirements, Sponsoring Institutions and programs should elicit feedback from the fellows who use them. Similarly, Sponsoring Institutions and programs may take different approaches to ensuring safety, security, and access to food, depending upon the nature of assignments and the availability of resources at participating sites. It is important for Sponsoring Institutions and programs to obtain fellow input when evaluating these aspects of the clinical learning environment. When assessing a program’s compliance, Review Committees place emphasis on what is reported by the Accreditation Field Representatives, from their interviews and/or observations during a site visit. I.D.2.c) …clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care. It is critical to acknowledge that the time for graduate medical education often overlaps with the time for starting and raising families. This overlap may serve as a source of stress for fellows. Rooms for lactation and other personal health care must provide privacy and refrigeration and be close enough to the clinical setting to be of use for the fellows who need them. Therefore, simply using a restroom as a facility for lactation or for 34 medication administration would not meet the standard of cleanliness. Refrigeration capabilities are essential for storage. In addition, the availability of a computer and telephone will allow fellows, if necessary, to provide continued attention to patient care while attending to their own personal health care needs. Interpretation of the requirement for “close proximity to clinical responsibilities” is left to the program and institution. The requirements do not dictate a specific distance or a time element for fellows to get from a facility to use to attend to personal health care needs to the clinical location. Instead, Sponsoring Institutions and programs are urged to consider the circumstances. For example, a busy, high-intensity clinical location, such as the intensive care unit, might require the lactation room has immediate access to the patient care area, whereas a less busy, less intense clinical location will not require such proximity. In addition, it is not necessary for the lactation or other personal health care needs facility to be solely dedicated to resident/fellow use. VI.C.1.d).(1) Fellows must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours Regarding fellows having the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours, fellows should give adequate notice of such appointments whenever possible, and requests should be handled in a professional manner. 35 Accommodations for Fellows with Disabilities Programs must work with their Sponsoring Institution to ensure compliance with institutional policies related to fellows’ requests for accommodation of disabilities. Common Program Requirements I.D.2. and I.D.2.e) are companions of ACGME Institutional Requirement IV.H.4., which states that “The Sponsoring Institution must have a policy, not necessarily GME-specific, regarding accommodations for disabilities consistent with all applicable laws and regulations.” Laws and regulations concerning requests for accommodation of disabilities include Title I of the Americans with Disabilities Act and related enforcement guidance published by the US Equal Employment Opportunity Commission. Other federal, state, and local laws and regulations may apply. It is common for program directors, coordinators, residents, fellows, faculty members, and designated institutional officials to collaborate with the Human Resources or Legal departments, and/or institutional officers/committees to manage requests for accommodations. Reference Material Sponsoring Institutions and programs must ensure that fellows have access to medical literature that supports their clinical and educational work. Common Program Requirement I.D.3. is parallel to ACGME Institutional Requirement II.E.2., which states, “Faculty members and fellows must have ready access to subspecialty-specific electronic medical literature databases and other current reference material in print or electronic format.” Review Committee members are aware that the availability of a computer or mobile device with internet access alone may provide access to a wide range of relevant reference material. Many Sponsoring Institutions and programs purchase subscriptions to information resources and services to supplement open access materials. As with other programmatic resources, interpretation of the requirement may depend on unique circumstances of participating sites, programs, faculty members, and fellows. Fellows and faculty members may provide valuable input to Sponsoring Institutions and programs regarding the adequacy of available medical literature resources. Resources to Support the Number of Residents/Fellows Programs, in partnership with their Sponsoring Institutions, must ensure there are resources to support the number of fellows appointed. If a program fails to demonstrate it has the capacity to provide each fellow with a sufficient educational experience, a Review Committee may reduce that program’s approved complement (ACGME Policies and Procedures, Section 19.500. 36 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement I.E. A fellowship program usually occurs in the context of many learners and other care providers and limited clinical resources. It should be structured to optimize education for all learners present. I.E.1. Fellows should contribute to the education of residents in core programs, if present . (Core) [The Review Committee may further specify] Background and Intent: The clinical learning environment has become increasingly complex and often includes care providers, students, and post-graduate residents and fellows from multiple disciplines. The presence of these practitioners and their learners enriches the learning environment. Programs have a responsibility to monitor the learning environment to ensure that fellows’ education is not compromised by the presence of other providers and learners, and that fellows’ education does not compromise core residents’ education. 37 GUIDANCE Although other learners and advanced practice providers can and frequently do enhance fellow education, there are certainly circumstances in which they interfere with that process. One example of such interference is the interposition of an advanced practice clinician in the communication of an attending physician faculty member and the fellow in such a manner that the fellow does not gain the educational benefit of direct communication with the attending physician faculty member. The presence of fellows from other subspecialties may lead to competition for clinical experiences such as procedures. Situations of this type frequently involve a degree of intra- or inter-departmental disagreement on educational responsibilities. In the case of advanced care clinicians, they may also impact decisions made by the administration of the clinical site. The designated institutional official and Graduate Medical Education Committee may be very helpful to the involved program(s) in arriving at an equitable and mutually beneficial solution to the issue. 38 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide background and Intent Common Program Requirement: II. Personnel II.A. Program Director II.A.1. There must be one faculty member appointed as program director with authority and accountability for the overall program, including compliance with all applicable program requirements. (Core) II.A.1.a) The Sponsoring Institution’s GMEC must approve a change in program director. (Core) II.A.1.b) Final approval of the program director resides with the Review Committee. (Core) Background and Intent: While the ACGME recognizes the value of input from numerous individuals in the management of a fellowship, a single individual must be designated as program director and made responsible for the program. This individual will have dedicated time for the leadership of the fellowship, and it is this individual’s responsibility to communicate with the fellows, faculty members, DIO, GMEC, and the ACGME. The program director’s nomination is reviewed and approved by the GMEC. Final approval of program directors resides with the Review Committee. 39 GUIDANCE The Review Committees want to help programs succeed. One essential element of program success is having a qualified individual as program director. Based on years of cumulative experience both with programs that are successful and those that are not so successful, many Review Committees have developed minimal qualifications for program directors in a subspecialty. Although a proposed program director has already been approved by the Sponsoring Institution’s Graduate Medical Education Committee (GMEC), final approval rests with the Review Committee. What does this look like in the Accreditation Data System (ADS)? For appointment of a new program director, the Sponsoring Institution’s GMEC must first approve the change. Following approval by the GMEC, the designated institutional official will enter the recommendation into the ACGME’s Accreditation Data System (ADS), and the following message will appear on the ADS page: 40 In addition, ADS will generate a letter to the program as follows: Check with the applicable Review Committee staff members to confirm whether a new program director appointment has been approved. 41 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement Common Program Requirement: II.A. Program Director II.A.2. The program director must be provided with support adequate for administration of the program based upon its size and configuration. (Core) [The Review Committee must further specify] [The Review Committee may further specify regarding support for associate program director(s)] Background and Intent: Twenty percent FTE is defined as one day per week. [This number will be modified to fit the level of support specified by the Review Committee] “Administrative time” is defined as non-clinical time spent meeting the responsibilities of the program director as detailed in requirements II.A.4.-II.A.4.a).(16). The requirement does not address the source of funding required to provide the specified salary support. 42 GUIDANCE Full-Time Equivalent, Percent Effort, and Hours per Week For the purpose of this requirement, one program director full-time equivalent (FTE) is equal to 40 hours per week dedicated to the program director role. Twenty percent of a program director’s work effort (or 0.2 FTE) is therefore equal to eight hours per week of non-clinical work that a program director devotes to the program. Non-Clinical Time Non-clinical time devoted to program administration, also referred to as “administrative time,” is defined as non-clinical time spent meeting responsibilities of the program director as detailed in Common Program Requirements II.A.4.-II.A.4.a).(16). Protected Time One way to demonstrate substantial compliance with this requirement is to establish and document at least eight hours per week of “protected time” for the program director during regular business hours. Protected time is an accommodation that allows program directors to devote most or all their efforts to the program, with limited or no responsibilities for patient care or clinical supervision. Program directors, regardless of specialty, require defined protected time to perform the many non-clinical responsibilities of leading and managing the program. The parameters of protected time are sometimes specified in agreements that determine compensation and other terms of program directors’ appointments. Salary Support and Sponsoring Institutions A Sponsoring Institution is not necessarily the entity that provides salary support directly to a program director, and in many cases, a program director’s employer is not a Sponsoring Institution. However, each accredited Sponsoring Institution is accountable to the ACGME’s Institutional Review Committee for ensuring that program directors receive salary support in substantial compliance with this requirement, even when the Sponsoring Institution does not provide a program director’s compensation (ACGME Institutional Requirements II.B., II.B.1. – see below). Related Institutional Requirements: II.B. Program Administration: The Sponsoring Institution, in partnership with each of its ACGME-accredited programs, must ensure the availability of adequate resources for resident/fellow education, including: II.B.1. financial support and protected time for the director(s) to effectively carry out educational administrative, and leadership responsibilities, as described in the Institutional, Common and specialty-subspecialty-specific Program Requirements; (Core) 43 What does this look like in the Accreditation Data System (ADS)? To enter the program director’s information, select from the drop-down list of active faculty members, select the program director’s name, and enter the information, accordingly, as shown in the screenshots below. The fields will be pre-populated if the information has previously been entered. (Disregard response selections.) 44 45 Percent of FTE Salary Support – Program Directors Programs must provide information on the percent of salary support (percent FTE) allocated to the program director for non-clinical time to devote to administration of the program. Percent of FTE Salary Support – Associate Program Directors If applicable, programs must provide information on the percent of salary support (percent FTE) allocated to the associate program director(s) for non-clinical time to devote to administration of the program. 46 Programs currently provide faculty certification data through manual entry. The ACGME can now provide Certification from the Source (via an agreement with the American Board of Medical Specialties). The American Osteopathic Association (AOA) will also be added to ADS, which will provide similar AOA certification data. The ACGME plans to phase out the manual entry of faculty certification data and provide automated data from Certification from the Source from the ABMS and AOA (when available). Faculty certification will be updated monthly. Refer to the following screenshot to see how this is displayed in ADS. All sections must be completed. The program director or faculty certification information is frequently incomplete or outdated, resulting in citations from the Review Committee. 47 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement II.A.3. Qualifications of the program director: II.A.3.a) must include subspecialty expertise and qualifications acceptable to the Review Committee; (Core) [The Review Committee may further specify] II.A.3.b) must include current certification in the subspecialty for which they are the program director by the American Board of _____ or by the American Osteopathic Board of _____, or specialty qualifications that are acceptable to the Review Committee; (Core) [The Review Committee may further specify acceptable subspecialty qualifications or that only ABMS and AOA certification will be considered acceptable] [The Review Committee may further specify additional program director qualifications] 48 GUIDANCE Some Review Committees will only accept certification in the appropriate specialty/subspecialty by an American Board of Medical Specialties member board or the American Osteopathic Association for a program director. Other Review Committees will accept other qualifications for the program director under particular circumstances. These may include a “board eligible” status, fellowship in the Royal College of Physicians and Surgeons of Canada, certification by other international bodies, or tenure in rank as a faculty member. 49 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement II.A.4. Program Director Responsibilities The program director must have responsibility, authority, and accountability for: administration and operations; teaching and scholarly activity; fellow recruitment and selection, evaluation, and promotion of fellows, and disciplinary action; supervision of fellows; and fellow education in the context of patient care. (Core) 50 GUIDANCE Simply put, the program director is the person who is ultimately responsible for the program. 51 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement II. Personnel II.A Program Director II.A.4. Program Director Responsibilities The program director must have responsibility, authority, and accountability for: administration and operations; teaching and scholarly activity; fellow recruitment and selection, evaluation, and promotion of fellows, and disciplinary action; supervision of fellows; and fellow education in the context of patient care. (Core) II.A.4.a) The program director must: II.A.4.a).(1) be a role model of professionalism; (Core) Background and Intent: The program director, as the leader of the program, must serve as a role model to fellows in addition to fulfilling the technical aspects of the role. As fellows are expected to demonstrate compassion, integrity, and respect for others, they must be able to look to the program director as an exemplar. It is of utmost importance, therefore, that the program director model outstanding professionalism, high quality patient care, educational excellence, and a scholarly approach to work. The program director creates an environment where respectful discussion is welcome, with the goal of continued improvement of the educational experience. II.A.4.a).(2) design and conduct the program in a fashion consistent with the needs of the community, the mission(s) of the Sponsoring Institution, and the mission(s) of the program; (Core) Background and Intent: The mission of institutions participating in graduate medical education is to improve the health of the public. Each community has health needs that vary based upon location and demographics. Programs must understand the social determinants of health of the populations they serve and incorporate them in 52 the design and implementation of the program curriculum, with the ultimate goal of addressing these needs and health disparities. II.A.4.a).(3) administer and maintain a learning environment conducive to educating the fellows in each of the ACGME Competency domains; (Core) Background and Intent: The program director may establish a leadership team to assist in the accomplishment of program goals. Fellowship programs can be highly complex. In a complex organization the leader typically has the ability to delegate authority to others, yet remains accountable. The leadership team may include physician and non-physician personnel with varying levels of education, training, and experience. II.A.4.a).(4) develop and oversee a process to evaluate candidates prior to approval as program faculty members for participation in the fellowship program education and at least annually thereafter, as outlined in V.B.; (Core) II.A.4.a).(5) have the authority to approve program faculty members for participation in the fellowship program education at all sites; (Core) II.A.4.a).(6) have the authority to remove program faculty members from participation in the fellowship program education at all sites; (Core) II.A.4.a).(7) have the authority to remove fellows from supervising interactions and/or learning environments that do not meet the standards of the program; (Core) Background and Intent: The program director has the responsibility to ensure that all who educate fellows effectively role model the Core Competencies. Working with a fellow is a privilege that is earned through effective teaching and professional role modeling. This privilege may be removed by the program director when the standards of the clinical learning environment are not met. There may be faculty in a department who are not part of the educational program, and the program director controls who is teaching the residents. 53 GUIDANCE II.A.4.a).(1) [The program director must:] be a role model of professionalism The intent of this section is to emphasize the importance of program director and faculty member leadership as noted in the associated Background and Intent. This includes role modeling professionalism, high quality patient care, educational excellence, and a scholarly approach to work. Leadership The concept of program director and faculty leadership takes many forms and is important regardless of a program’s size. The designation of faculty leadership can be a formal or an informal process, but what is most important is the composition of this group. The faculty leadership group can be composed of physicians and non-physicians who know the fellows well, have frequent interactions with them, and most importantly, can serve as role models in clinical care, professionalism, and scholarship. In addition, they can serve as a sounding board for the program director and help shape the program. As ACGME President and CEO Dr. Thomas J. Nasca stated (2015): “The philosophical roots of professionalism include the Hippocratic tradition of medicine as a moral enterprise; the transition of medicine from guild to profession with a commitment to competence, altruism, and public trust; and the responsibility of the profession to prepare the next generation of physicians to serve the public.” The following schematic provides and overview of Dr. Nasca’s thoughts: 54 Mentorship While there are many articles that define and describe mentoring and mentorship, a number of characteristics constitute this relationship. Mentorship is a long-term relationship between a more senior person (mentor) and a less experienced person (mentee). While both benefit from the relationship, it is generally established for the betterment of the mentee. According to Sambunjak and Marusic (Sambunjak, Dario, and Ana Marušić. “Mentoring.” JAMA 302, no. 23 (2009): 2591. https://doi.org/10.1001/jama.2009.1858.), mentorship includes three components: 1) helping mentees acquire and integrate new learning; 2) managing a personal aspect of transitional states; and 3) maximizing the mentee’s potential to become a fulfilled and achieving practitioner. Mentorship therefore helps keep the promise that a physician makes to educate the next generation of physicians to serve patients. Tjan (Tjan, Anthony K. “What the Best Mentors Do.” Harvard Business Review, December 5, 2017. https://hbr.org/2017/02/what-the-best-mentors-do.) interviewed scores of leaders and concluded that successful mentors have four characteristics: 1) they put the relationship before the mentorship; 2) they focus on character rather than competence and on shaping character, values, self-awareness, empathy, and capacity for respect; 3) they “shout loudly with optimism, and keep quiet with cynicism;” and 4) they are more loyal to their mentees than to the companies. In-Text and Additional References Lacombe, Michael A. 1990. “Recent Advances.” The American Journal of Medicine 88, no. 4: 407–8. https://doi.org/10.1016/0002-9343(90)90497-2. Nasca, Thomas J. “Professionalism and Its Implications for Governance and Accountability of Graduate Medical Education in the United States.” 2015. JAMA 313, no. 18 (December): 1801. https://doi.org/10.1001/jama.2015.3738. Sambunjak, Dario, Sharon E. Straus, and Ana Marušić. 2006. “Mentoring in Academic Medicine.” JAMA 296, no. 9 (June): 1103. https://doi.org/10.1001/jama.296.9.1103. This is from a speech given by Dr. Michael LaCombe, a physician who has dedicated his life to education in the importance of mentorship and bedside teaching, delivered at the William Morgan Teaching Symposium at the University of Rochester, July 1989: In a hospital cafeteria, two residents were arguing over lunch. Oblivious to the high-tech plastic and steel surrounding them, they were locked in a heated, and unwinnable battle: what was the single most important discovery in the history of medicine? Understand that these were modern doctors with fashionable ideas and a trendy impatience with history. They had long since discarded Harvey’s dissections, Morton’s anesthesia, and Koch’s postulates. The first resident, a latter-day traditionalist, argued for the discovery of antibiotics. Eating his salad with his fingers in a grand display of entitlement, he began his argument: “There is no doubt that the dawn of the antibiotic era is indisputably the beginning of modern medicine. Domagk’s sulfonamides, Waksman’s streptomycin, Fleming’s 55 penicillin, all gave physicians something more to do than simply monitor the dying patient. Antibiotics gave us credibility, a bona fide raison d’etre. And beyond that, their discovery has spawned the whole discipline of infectious disease, whose premise, the treatment of disease by biochemical means, has in turn fathered other disciplines as well.” Eminently pleased with himself, he leaned back in his chair. The second resident, more modernistic than the first prided himself on his intuitive leaps and lateral thinking. He could hardly settle for any such simplistic solution from history as his colleague had proposed. His cleverness made him positively bubble forth. “Antibiotics are important and they have their place, but they are so crude. Consider their toxicity, the emergence of resistance and the very enigma of AIDS. Antibiotics are merely an interim measure. No my friend, you miss the obvious.” In fact, he believed that his solution was not all that obvious, but understatement would magnify his own genius. “The discovery of the computer is the Rosetta stone for medicine. Regard the computer’s application in medical research. Think of the microchips used in autoanalyzers, in monitoring devices, and in nuclear scanning. Consider what the CT scan has done just in the field of neurology alone. And that only scratches the surface. We can implant microchips in occipital lobes to enable the blind to see. We can use microchips in electronic limbs for amputees. And imagine the microprocessor-coordinated cochlear implants for the deaf, artificial kidneys and programmable pacemakers. Even genetic engineering depends upon computers to direct genetic analyses and sequencing.” Enough was enough. He had won and he knew it. He now sat back smugly. At the end of their table sat an old man in a long white coat. He too ate his salad with his fingers. He had forgotten his fork. To this elderly physician, the first resident appealed: “What do you think sir? He asked condescendingly. What would you consider medicine’s greatest achievement?” The old man returned a leaf of lettuce to his salad bowl, wiped his fingers with a napkin and considered both residents with absent regard. He began to speak, reconsidered, and looked away and out the windows, and then remembered that he had been asked a question. “You are both correct as far as you go, which isn’t very far, which therefore makes you both wrong, I suppose. And the correct answer to your question may be found really in your asking me, or in your need of asking me, rather more correctly, and in my compulsion to answer you, or rather history’s compelling me to do so, more exactly.” Alzheimer’s, thought the first resident. Korsakoff’s, thought the second resident. But the old man only munched on a celery stalk, looked away briefly as if to 56 summon his facilities, and then turned his attention to his salad again. Huh? Asked the first resident. I beg your pardon, asked the second. “The mentor” whispered the old man. What? Both residents replied in unison. The old gentleman wiped his lips, placed both hands on the table, stared off, and began. “The mentor is medicine’s single greatest achievement, though no one set out to invent this idea to win any prize. It started, I am sure, long before Hippocrates, though he’s gotten most of the press for it. But just stop and consider Hippocrates himself. There he is sitting in his robe, surrounded by colonnades, fist under his chin, lounging on some piece of marble. Through observation, by sheer power of thought he’s trying to make a science out of what had been only magic and religion. Pretty soon he has a group of young people sitting around him as well, all wanting to learn what he, Hippocrates knows to be important. So he teaches them all he knows, which is what you’re supposed to do when you’re a mentor. And then he sends them out into the world. They teach others in turn, each of them becoming a mentor for students as Hippocrates had been for them. And everywhere they go, teaching students, treating patients, as Hippocrates had taught them to do. Hippocrates is right there at their elbows, making sure they do it the right way, and with style. And so it goes through history – from Aristotle to Herophilus, from Galen to Vesalius, Bernard, Pasteur, Whipple, and…well, you know history as well as I do.” The old man continued. “Look what happens with this mentor business. You have teachers each with students numbering in the thousands, all linked with each other down through the ages – forming a vast, dendritic coalescence of medical knowledge. Why, you have to be proud just to belong to it, just to be allowed to pass on a few bits and pieces of information yourself! You begin to think of yourself as some living page out of a grand medical textbook. And what happens to those young doctors when they are adrift in the world? Do their mentors desert them? Not on your life! A student meets a patient with congestive heart failure, and old man Withering is right there with him, telling him how much foxglove to grind up. Or a young doctor is dealt a baffling case, with an endless array of signs and symptoms, and all of a sudden Sydenham is sitting on her shoulder, making sure she takes down the patient’s history correctly and that the observations are precisely made. And so it’s been for me these long years. I’ve carried my mentor everywhere. If I get sloppy, I wonder “what would he think of me now?” And if I am in a tight spot clinically, he prods me back to the literature. When I am impatient with my patients, I remember his patience with me. When I’m asked to teach, I do so willingly because that is what he did. When I begin to doubt myself, I remember his belief in me. And if I am ready to quit, I can see him standing there before me in his long white coat with stern look and stethoscope, and I go on. 57 What has he been for me, this mentor of mine? He’s been like a father to me, but more than a father. He has been my companion in medicine, to help me through the loneliness that medicine can bring and to share with me the joy that medicine can be. My mentor has, through me and those of my students cared decently and compassionately for countless patients. When I have cured a patient or two, why, so has he. And so has Cushing and Koch before him. Yes sir, the mentor is medicine’s best invention. All of us doctors need one. That’s what it’s all about. I hope you boys have one yourselves.” The old man stopped, looked off, and smiled at some distant memory. The residents at the next table had turned to listen to him as well. The old man got up to leave, nodding to them all. He had a gleam in his eye, a radiance about him. He straightened his shoulders, raised his chin and turned with a quote: “Observation, reason, human understanding, courage – these make the physician. Men must be taught as if you taught them not, and things unknown proposed as things forgot.” Now the old man turned back to the two residents at his table, nodded to them, put his head down and turned to walk away. Suddenly he remembered a final quotation and turned back to them all with a smile: “A man who is not fond of students and who does not suffer their foibles gladly, misses the greatest zest in life.” With a hand to his breast, the old man gave a slight bow, turned, and shuffled away. Humanism Humanism in health care is characterized by a respectful and compassionate relationship between physicians and their patients. It reflects attitudes and behaviors that are sensitive to the values and the cultural and ethnic backgrounds of others. The humanistic health care professional has two key attributes: altruism and empathy. Chou et. al stated that “Humanism in medicine combines scientific knowledge and skills with respectful, compassionate care that is sensitive to the values, autonomy and cultural backgrounds of patients and their families” (Chou et al. 2014). Evidence demonstrates that compassion and empathy are critical components of good medicine. When provided with humanistic care, patients are more likely to adhere to their treatment regimens, and this adherence makes it more likely that they adhere to preventive practices and may heal more quickly. Studies indicate that the characteristics of humanism can be taught. While Chou et. al acknowledged this, they sought to determine how humanism can be maintained in a world of increasing demands and technologies. They interviewed faculty members in internal medicine who had been identified by the residents to be excellent role models for humanism. They found three themes: 1) attitudes needed to sustain humanism included humility, curiosity, standard of behavior (“I treat patients the way I would want to be treated”), importance for the patient, importance for the physician (joy in caring for patients), and more than just the disease (“my role is being there with and for the patient”); 2) habits included self- reflection, seeking a connection with the patients, teaching/role modeling (“knowing that 58 I’m responsible not just for the patients in front of me, but modeling how my students and residents are going to treat their patients.”), balance, and mindfulness and spiritual practices; and 3) humanism and maintenance of humanism in medical practice takes effort. Many of the physicians interviewed noted that humanism takes deliberate, intentional work, and identified the need for environmental support. While one may conclude that the work that goes into deliberative practice of humanism imposes additional workload on physicians that leads to burnout, the physicians in the study believed that humanism, as represented by the joy in caring for patients and educating residents, actually was a deterrent to burnout. In-Text and Additional References Chou, Carol M., Katherine Kellom, and Judy A. Shea. 2014. “Attitudes and Habits of Highly Humanistic Physicians.” Academic Medicine 89, no. 9: 1252-58. https://doi.org/10.1097/acm.0000000000000405.) Montgomery, Lynda L, Sana Loue, and Kurt C Stange. 2017. “Linking the Heart and the Head: Humanism and Professionalism in Medical Education and Practice.” Family Medicine 49, no. 5: 378-83. https://www.stfm.org/FamilyMedicine/Vol49Issue5/Montgomery378 II.A.4.a).(2) [The program director must:] design and conduct the program in a fashion consistent with the needs of the community, the mission(s) of the Sponsoring Institution, and the mission(s) of the program The aim of the requirement is to bring intentionality to the development, design, and implementation of each fellowship program in consideration of the needs and desires of its stakeholders. It is probably not realistic for a small program based in a critical access hospital to hold as its mission the production of the next generation of physician scientists. Likewise, it is probably not realistic for a program based in a very large quaternary referral hospital in a major metropolitan area to hold as its mission the production of physicians who will bring care to medically underserved areas. It is probably accurate to assume that most programs have not in the past developed and clearly articulated their mission with the input of the communities they serve, their fellows, their Sponsoring Institution, and others. Although the process may prove to be time consuming, it will likely prove rewarding for all involved. Once developed, the mission of the program should periodically be reevaluated for potential improvement, again incorporating input from stakeholders. Defining Program Aims • Set aims as part of self-identified annual improvement process o Who are our fellows? o What do we prepare them for?  Academic practice  Leadership and other roles o Who are the patients/populations we care for? 59 Fellow participation is critical: After all, they are the beneficiaries of the educational program • They have firsthand knowledge of areas that need improvement (they are in the trenches) • Double benefit: o Fellows help improve their own education. o Fellows’ participation in “educational QI effort” can be used to meet the requirement for fellow involvement in quality and safety improvement. Examples of Program Aims 1. Provide a comprehensive two-year curriculum to enable fellows to learn secondary and tertiary care skills in all settings 2. Educate fellows to be excellent practitioners of pain medicine in a multidisciplinary team model 3. Train individuals with expertise in population health and serving medically underserved 4. Produce excellent, independent practitioners who will be local and national leaders, and for academic careers Benefits of Defining Program Aims 1. Suggests a relevant dimension of the program What kinds of graduates do we produce for what kinds of practice settings and roles? 2. Allows for a more “tailored” approach to creating a learning environment a. Focusing on specific aims can produce highly desirable “graduates” that match patient and health care system needs (Hodges 2010). 3. Enhances the focus on functional capabilities of graduating fellows Fits with a Milestones-based approach to assessment II.A.4.a).(5)-(7) [The program director must:] have authority to approve/remove program faculty members or remove fellows from supervising interactions and/or learning environments that do not meet the standards of the program II.A.4.a).(5)-(7): These requirements provide the program director with the authority to evaluate and approve program faculty members for participation in the education of fellows. This applies to faculty members at both the primary clinical site and at participating sites. It is important that faculty members who participate in the education of fellows are interested in, and dedicated to the fellowship program. II.A.4.a).(6): The requirement that the program director have the authority to remove program faculty members from participation in the fellowship program at all sites is often misunderstood. This requirement does not mean that the program director can terminate the employment of a faculty member. What it does mean is that the program director has the authority to remove a faculty member from the teaching service. For example, if a faculty member on the teaching service is consistently reported as being 60 unable to, or refuses to teach, berates the fellows, and is generally not available for educational activities, the program director may decide to remove the faculty member from the teaching service. However, the faculty member may still continue with other clinical and administrative responsibilities within the department as delineated by the department chair. II.A.4.a).(7): The program director has the authority to remove fellows from supervising interactions and/or learning environments that do not meet the standards of the program. For example, fellows might be assigned to a participating site for a one-month rotation, where they report that they are only there to provide service. Faculty members at the site do not provide supervision, evaluation, or education and are not available for teaching. The program director may decide to discontinue the rotation and have the fellows rotate to another participating site that can provide the educational experience. Processes for Raising Concerns, Providing Feedback, and Submitting Grievances See Common Program Requirements II.A.4.a).(13) to (13).a. In-Text Reference Hodges, Brian David. 2010. “A Tea-Steeping or i-Doc Model for Medical Education?” Academic Medicine 85. https://doi.org/10.1097/acm.0b013e3181f12f32.) 61 REQUIREMENTS Text in italics are “philosophic” statements Text in boxes provide Background and Intent Common Program Requirement II. Personnel II.A Program Director II.A.4. Program Director Responsibilities The program director must have responsibility, authority, and accountability for: administration and operations; teaching and scholarly activity; fellow recruitment and selection, evaluation, and promotion of fellows, and disciplinary action; supervision of fellows; and fellow education in the context of patient care. (Core) II.A.4.a) The program director must: II.A.4.a).(8) submit accurate and complete information required and requested by the DIO, GMEC, and ACGME; (Core) 62 GUIDANCE The submission of incomplete and/or inaccurate information by a program is likely one of the most common citations given by the Review Committees. Examples include: 1. A Program Letter of Agreement (PLA) is non-existent, outdated, does not have the appropriate components, lacks requisite signatures, or doesn’t include a listing of participating sites 2. Incorrect block diagram 3. Program director and faculty member qualifications are inadequate or missing information 4. Incorrectly completed curriculum vitae or Faculty Roster a. Board certification status 5. Scholarly activity information left blank 6. Inadequate responses to citations 7. Lack of goals and objectives, or goals and objectives that are not level- or rotation-specific 8. Inappropriate levels of supervision 9. Missing clinical experience information (no patient data) 10. Accreditation Field Representative had to spend a significant amount of time during an accreditation site visit to make clarifications, corrections, and look for missing information. The ACGME created three brief videos to help with: 1) creating a block diagram; 2) responding to citations; and 3) providing information for scholarly activity. Review this video on Avoiding Common Errors in the ADS Annual Update-Creating an Effective Block Schedule Video Total Viewing Time: 9 minutes Click on the picture above to be directed to the video 63 Block Diagrams When preparing an application for a new program within the ACGME’s Accreditation Data System (ADS), instructions are provided for completing a block diagram. Note that the block diagram may need to be updated to reflect future changes in the program. Guide to Construction of a Block Diagram A block diagram is a representation of the clinical and educational experiences of a fellow in a given post-graduate year. It offers information on the type, location, length, and variety of rotations for that year. The block diagram shows the rotations a fellow would have in a given year; it does not represent the order in which they occur. There should be only one block diagram for each year of education. The block diagram should not include fellow names. What does this look like in the Accreditation Data System (ADS)? While all the screenshots below indicate “resident” or specialty information, “fellow” or subspecialty information is presented when a fellowship program is entered. NOTE that the ADS format may change to reflect updates to the Common Program Requirements Guide to Construction of a Block Diagram A block diagram is a representation of the rotation schedule for a resident in a given postgraduate year. It offers information on the type, location, length, and variety of rotations for that year. The block diagram shows the rotations a resident would have in a given year; it does not represent the order in which they occur. There should be only one block diagram for each year of education. The block diagram should not include resident names. • Create and upload a PDF of your program’s block diagram using the information below as a guide. • Two common models of the block diagram exist: the first is organized by month; the second divides the year into 13 four-week blocks. Rotations may span several of these time segments, particularly for subspecialty programs. Both models must indicate how vacation time is taken. This can be done by allocating a time block to vacation, or by indicating this in a “Notes” section accompanying the block diagram. Examples of other less common models are also provided below. 64 • In constructing the block diagram, include the participating site in which a rotation takes place, as well as the name of the rotation. If the name of the rotation does not clearly indicate the nature of the rotation, then clarifying information should be provided as a footnote to the block diagram or elsewhere in the document. • Group the rotations by site. For example, list all of the rotations in Site 1 first, followed by all of the rotations in Site 2, etc. The site numbers listed in the Accreditation Data System (ADS) should be used to create the block diagram. • When “elective” time is shown in the block diagram, the choice of elective rotations available for residents should be listed below the diagram. Elective rotations do not require a participating site. • Clinical rotations for some specialties may also include structured outpatient time. For each rotation, the percentage of time the resident spends in outpatient activities should be noted. • Clinical rotations for some specialties may also include structured research time. The fourth line of the schedule should be used to represent the percentage of time devoted to structured research on a clinical rotation. If a block is purely research, it should be labeled as such, and should not be associated with a participating site. • If needed, additional information to aid in understanding your program’s block diagram may be entered in a “Notes” section at the end of the Block Diagram Data Collection Form. 65 Note that some of the Review Committees use a specialty-/subspecialty-specific block diagram, and do not accept a common block diagram in ADS. For these specialties, the program will not see the sample block diagram on the right but rather a link to the specialty instructions, per the screenshot below: 66 ADS Annual Update Program directors receive an email from the ACGME each year with a reminder to perform the required Annual Update in ADS. The screen shows a series of topics with drop-down lists, and the program information indicates the need to upload the current block diagram(s) for the program. Review Committee Uses for the Block Diagram: 1. To review rotation length(s) 2. To get a summary of time spent in each program site 3. To get a summary of time spent on each rotation type 4. To confirm elective time The block diagram should clearly illustrate the rotation length (or lengths) used by a program. The rotation length has educational implications in that the longer the rotation, the greater the opportunity faculty members have to observe and assess the fellow to provide more accurate evaluations and more specific feedback. The rotation length also has clinical implications in that shorter rotations result in a greater number of team turnovers. The block diagram also provides (in probably the most concise format available), a summary statement of how much time a fellow in a given program spends in each of the clinical sites used by that program, and clearly illustrates what specific experiences are gained at each of those sites. A well done block diagram, then, also illustrates how much cumulative time a fellow spends in a particular required clinical experience or subspecialty area through all of the clinical sites used by the program. Program Uses for the Block Diagram: 1. Help to ensure that Program Requirements are met 67 2. Help to ensure that certifying board requirements are met 3. May be useful in recruitment The block diagram helps the program ensure the Program Requirements are being met. Many certifying boards require that candidates have fulfilled certain chronological educational requirements. It may be as simple as a total number of aggregate clinical months. It may also be a detailed requirement for a certain number of months of clinical experience. A well done block diagram provides potential applicants with a quick but detailed snapshot of what they could expect each year if they entered that particular program. When a program is contemplating or requesting a permanent increase in its fellow complement, a block diagram created for each of the years anticipated to be required for the transition to the new full complement is extremely useful. In this way, the program can ensure each rotation and clinical site will have an appropriate number of residents or fellows (Goldilocks rule: not too many, not too few, just enough) at any time during the transition. And it can ensure that each resident or fellow completing the program during the transition has met all chronological experience requirements for the applicable certifying board. It also helps the Review Committee understand the local implications of the requested complement increase, and demonstrates to the Review Committee that the program has thought through the implications in detail. Institutional (DIO) Use for the Block Diagram: The block diagram provides the Sponsoring Institution and designated institutional official (DIO) with a structure for oversight and information required to plan resources for curricular and other needs. Rotation schedules are very important to the fellows, the faculty members, and others, but rotation schedules are NOT block diagrams and are not required by the ACGME. A block diagram provides information regarding program plans for fellow experiences in each year of the program, but does not show a rotation schedule for each individual. A Block Diagram IS: 1. a representation of typical rotations assigned each program year 2. flexible in showing rotation lengths 3. able to show other important information: a. inpatient time on a rotation b. outpatient time on a rotation c. research time on a rotation d. names of site directors e. rotation(s) offering particular required experience(s) 68 A block diagram shows each of the rotations a fellow will typically be assigned in each post-graduate year of the program. It also shows the amount of time a fellow will spend on each of these rotations, and the clinical sites at which those rotations will occur. A block diagram is flexible in that it can show rotations as short as one week or as long as several months. It can also be used to convey other important information about the structure of the program. TIPS: 1. Show program name and number 2. Clearly identify each clinical site 3. Site numbers must be consistent 4. Clearly explain any abbreviations 5. Clearly explain any local jargon 6. Differentiate rotations with the same name 7. Identify rotations for key clinical experience Curriculum Vitae and Faculty Information ADS Instructions: The Faculty Roster instructions vary by specialty. For Specialties and Subspecialties: List all faculty members who have a role in the education of fellows with competence to instruct and supervise. List the program director first. All faculty members must: Be role models of professionalism • Demonstrate commitment to the delivery of safe, quality, cost effective, patient-centered care • Demonstrate a strong interest in the education of residents • Devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities • Administer and maintain an educational environment conducive to educating residents • Regularly participate in organized clinical discussions, rounds, journal clubs, and conferences • Pursue faculty development designed to enhance their skills at least annually • Establish and maintain an environment of inquiry and scholarship Following are screenshots that show data points for faculty information in ADS. 69 70 Following data entry for faculty CVs, the information will be displayed in table format as shown in the sample below: 71 Minimum Requirements The Faculty Roster must list faculty members with specialized expertise in the following specialties and subspecialties: [Note: The presented list varies according to specialty/subspecialty] Faculty Roster: Below are the key terms: 1. Filtering faculty: The Faculty tab defaults to all active faculty. To view physicians, non-physicians, core or inactive faculty only, change the filter at the top of the list. 2. Adding Faculty: To add faculty (physician or non-physician) - click the "Add Faculty" button. For specialties that use case logs, DO NOT enter attendings on this page unless the attending is also a faculty member. To add case log attendings, click the "Case Log Attendings" button on the right hand side of the screen or go to the "Case Logs tab". 3. Removing Faculty: If a faculty member is no longer active in the program, click "Edit" next to the faculty member's name and enter a "Date Left Program". The faculty member will then be moved to "Past/Inactive Faculty". 4. Sort/Reorder: To sort physician faculty, click the "Reorder" button. This screen will allow you to sort physician faculty only. 5. Physician/Non-physician data entry error: If a faculty member was entered in error as a physician/non-physician, you can convert the faculty member by clicking "Edit" next to the faculty name and clicking the button to "Convert" to physician or non-physician. 6. Core Faculty: Core faculty members must have a significant role in the education and supervision of residents and must devote a significant portion of their entire effort to resident education and/or administration, and must, as a component of their activities, teach, evaluate, and provide formative feedback to residents. They support the program leadership in developing, implementing, and assessing curriculum and in assessing residents’ progress toward achievement of competence in the specialty. Core faculty members should be selected for their broad knowledge of and involvement in the program, permitting them to effectively evaluate the program. 7. Chair of Department: For programs th