Guidebook for Clerkship Directors
Shortly before his death in 1321, Dante Alighieri completed Divine Comedy. One of the most important works in literature, Comedy consists of three parts: The Inferno, The Purgatorio, and The Paradiso. To describe his journey through The Inferno, Dante divides Hell into nine circles, from “virtuous pagans” (Circle I) to “compound fraud” (Circle IX).1 To explain the chaotic environment that is medicine in the United States at the beginning of the 21st century, this chapter is organized similarly to Dante’s Inferno.
As academic leaders, clerkship directors are expected to understand the organizational structure of American medicine. To ensure their professional development, clerkship directors should navigate many organizations, particularly those bodies that evaluate educational programs and physicians. Clerkship directors should also use resources offered by organizations that represent academic medicine or their specialty. And, clerkship directors should take advantage of opportunities to participate in national organizations, which will increase their academic recognition.
Like Dante’s Inferno, this chapter uses nine circles to explain American medicine and to introduce clerkship directors to the “alphabet soup” that accompanies these circles:
With 250,000 members (including medical students, residents, fellows, and physicians), the American Medical Association (AMA) is the largest physician organization in the world. During the past decade, however, fewer physicians joined AMA. In the mid-1990s, more than 40 percent of all physicians were AMA members, compared to 26 percent today; only 17 percent of practicing physicians under the age of 40 are currently AMA members.2 This decline, In part, is a result of the greater specialization of physicians and the increased prominence of specialty-specific societies, which are outlined later in this circle and in Circle III.
AMA’s loss of members raises several important issues. From an educational perspective, AMA sponsors several oversight entities, such as the Liaison Committee for Medical Education (LCME), the Accreditation Council for Graduate Medical Education (ACGME) and each of the 26 specialty-specific Residency Review Committees (RRCs), and the Accreditation Council for Continuing Medical Education (ACCME). Will another organization administer ACGME if AMA cannot? The AMA also plays a key role in representing physicians to the federal government in terms of reimbursement, especially related to the payment mechanisms under the Medicare and Medicaid programs. Which organization will assume this responsibility if AMA cannot? The AMA also leads efforts to develop Current Procedural Terminology (CPT) codes, which are the language of billing, documentation, and coding for health care in the United States. How can physicians keep ownership of this critical aspect of the business of medicine without a multi-specialty organization as the final arbiter? And finally, AMA attempts to coordinate efforts by physicians to lobby Congress. Which organization has the clout to represent physicians before government if AMA cannot?
One possibility is the Council of Medical Specialty Societies (CMSS). “Founded in 1965 as the Tri-College Council, CMSS was created to provide an independent forum for the discussion by medical specialists of issues of national interest and mutual concern” (3). Membership in CMSS “is limited to those US medical specialty societies that represent diplomates certified” by one of the American Board of Medical Specialties’ (ABMS) 24 specialty-specific boards.3 Currently, CMSS consists of 19 national specialty organizations representing more than 412,000 physicians nationwide. As opposed to AMA, CMSS is not as well known, and many of the nearly 500,000 physicians may not be aware that they are “represented” by the council.
In addition to AMA and CMSS, seven organizations attempt to represent the entirety of each of the major physician disciplines:
The Association of American Medical Colleges (AAMC) is the leading organization in the academic medical community. The community also includes the Association of Academic Health Centers (AAHC), the University Health System Consortium (UHC), and the Alliance of Independent Academic Medical Centers (AIAMC).
Founded in 1876, AAMC originally represented only medical schools. Today, AAMC represents the 125 accredited medical schools in the United States; 17 accredited Canadian medical schools, nearly 400 teaching hospitals, 94 academic societies representing 109,000 faculty members, and 67,000 medical students and 104,000 residents.4 To represent this broad constituency, AAMC consists of the Council of Deans (COD), the Council of Teaching Hospitals and Health Systems (COTH), the Council of Academic Societies (CAS), the Organization of Student Representatives (OSR), and the Organization of Resident Representatives (ORR).
The AAMC also includes nearly 15 professional development groups:
AAHC has more than 100 members. To belong to AAHC, an institution must include “an allopathic or osteopathic school of medicine, at least one other health professions school or program, and one or more teaching hospitals at major universities throughout the United States.”5 In contrast, UHC “is an alliance of the clinical enterprises of 88 academic health centers.”6 Therefore, UHC concentrates on the clinical mission, AAHC addresses the education and research missions, and AAMC tackles the tripartite mission.
Unlike AAMC, AAHC, and UHC—which revolve around medical schools—AIAMC members “are affiliated with medical schools but are independent of medical school ownership or governance” (7). As a result, the alliance is “a national network of large academic medical centers and health systems,” particularly teaching hospitals with residency programs accredited by ACGME.7
Interestingly, AAMC, AAHC, UHC, and AIAMC use different definitions for academic health center (AHC). In fact, the organizations use AHC and academic medical center (AMC) interchangeably. Clerkship directors should understand three points about this issue. First, AHC is considered a more appropriate term than AMC because it includes health professionals beyond physicians, such as nurses. Second, there is considerable sensitivity about what constitutes an AHC. Some experts (such as AAHC) believe an AHC includes a medical school, another health professions school or program, and a teaching hospital. Other authorities (such as AIAMC) assert that a major teaching hospital constitutes an AHC. Third, and not surprisingly, AAMC has survey data that indicate the majority of Americans do not know what an AHC is; the public understands the meaning of medical school and teaching hospital.8
The organizations in Circle I (AMA, CMSS, and the specialty societies) tend to consist of practicing physicians, while the organizations in Circle II represent academic medicine across specialties. Circle III includes organizations that represent faculty leaders (clerkship, program, and fellowship directors as well as chairs) by department. Because each specialty is unique, the easiest way to understand these organizations is by examining the seven major specialties and the associated faculty groups:
Most specialties include umbrella organizations. In internal medicine, for example, AAIM includes the academically focused internal medicine organizations, while the Federated Council for Internal Medicine consists of the American Board of Internal Medicine (ABIM), ACP, APDIM, ASP, and Society of General Internal Medicine. In Pediatrics, the Council on Pediatric Education (COPE) includes members from AAP, Ambulatory Pediatric Association (APA), American Board of Pediatrics (ABP), American Pediatric Society (APS), AMSPDC, APPD, COMSEP, Canadian Paediatric Society (CPS), Medicine-Pediatrics Program Directors Association (MPPDA), National Association of Children’s Hospitals and Related Institutions (NACHRI), Society for Adolescent Medicine (SAM), Society for Developmental & Behavioral Pediatrics (SDBP), and Society for Pediatric Research (SPR).
In addition to these academic specialty organizations, two coalitions attempt to unify clerkship and program directors. First, the Alliance for Clinical Education (ACE)—which produces this manual—attempts to “foster collaboration across specialties to promote excellence in clinical education of medical students.”9 Created in 1992, ACE consists of:
Second, the Organization of Program Director Associations (OPDA) attempts to “promote the role of the residency director and residency program director societies in achieving excellence in graduate medical education.”10 Established in 2000, OPDA is a consortium of residency program director societies in each of the medical and surgical specialties that correspond to 27 residency review committees within the ACGME (26 specialties and one for transitional year programs).
Analogous to ACE and OPDA, the International Association of Medical Science Educators represents the teachers of basic sciences.
Four major organizations oversee the evaluation of individual physicians: the Federation of State Medical Boards (FSMB), through medical boards; the National Board of Medical Examiners (NBME), through a three-step examination; the Educational Commission for Foreign Medical Graduates (ECFMG), through a certificate program; and ABMS, through specialty-specific boards.
Founded in 1912, FSMB consists of “the medical boards of the United States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands and 13 state boards of osteopathic medicine.”11 These boards are responsible for licensing physicians to practice in each state, district, or territory. NBME was founded in 1915 “because of the need for a voluntary, nationwide examination that medical licensing authorities could accept as the standard by which to judge candidates for medical licensure.”12
Together, NBME and FSMB administer the United States Medical Licensing Examination (USMLE), which consists of three steps. Step 1 “assesses whether medical school students or graduates can understand and apply important concepts of the sciences basic to the practice of medicine.”12 Step 2 “assesses whether medical school students or graduates can apply the medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision.”12 To meet these goals, Step 2 consists of two parts; the first measures clinical knowledge, while the second assesses clinical skills. The clinical skills assessment is a recent addition to the certifying examination process, so its impact is unknown. Step 3 “assesses whether medical school graduates can apply the medical knowledge and understanding of biomedical and clinical science considered essential for the unsupervised practice of medicine.”12 Usually, physicians-in-training take Steps 1 and 2 of USMLE during medical school and Step 3 after they complete the first year of residency training.
In most cases, graduates of US medical schools (USMGs) use the National Resident Matching Program (NRMP) and the Electronic Residency Application Service (ERAS) to match into residency programs in the United States. NRMP is an independent organization sponsored by AAMC, ABMS, American Hospital Association (AHA), AMA, and CMSS; AAMC sponsors ERAS. Through its certification program, ECFMG “assesses the readiness of international medical graduates (IMGs) to enter accredited residency or fellowship programs in the United States.”13
After successfully completing medical school, USMLE, and residency training, physicians can pursue certification. ABMS consists of 24 specialty-specific boards “to provide assurance to the public that those certified by an ABMS Member Board have successfully completed an approved training program and an evaluation process assessing their ability to provide quality patient care in the specialty.”14 In 2000, ABMS limited the validity of its certificates to 7 to 10 years. To recertify diplomates, the 24 specialty-specific boards use maintenance of certification (MOC), which is a program “to develop a continuous and credible evaluation process that is valuable to physicians, patients, and the healthcare system.”14
The specialty-specific boards within ABMS have twin responsibilities for evaluating physicians. First, the boards evaluate physicians after they complete residency and, if applicable, fellowship training. Second, the boards evaluate certified physicians every 7 to 10 years during their careers. In the United States, certification and MOC are voluntary processes for physicians.
Through various mechanisms, FSMB (and state medical boards), NBME, ECFMG, and ABMS (and its 24 specialty-specific boards) evaluate individual physicians. Several other organizations are responsible for assessing educational programs, including LCME, ACGME, and ACCME.
Sponsored by AAMC and AMA, LCME “is the nationally authorized accrediting authority for medical education programs leading to the MD degree in US and Canadian medical schools.”15 The American Osteopathic Association accredits osteopathic medical schools. The LCME certification process involves an extensive self-study component that generates a sizeable manuscript. This manuscript describes the medical school from the perspectives of the students, faculty, and administrators. LCME conducts an extensive site visit of the school that relies on defined assessment standards. These standards are available on the web at www.lcme.org/standard.htm.
ACGME is responsible for accrediting nearly 8,000 residency and fellowship programs in the United States. “To develop and refine its accreditation standards and to review accredited programs for compliance with the standards,” ACGME relies on 27 RRCs, one for each specialty and “one for a special one-year transitional year general clinical program.”16
Each RRC includes six to 15 volunteer physicians appointed by ACGME member organizations (AAMC, ABMS, the American Hospital Association, AMA, and CMSS) and the appropriate medical specialty boards and organizations (such as the American Board of Surgery and ACS, respectively, for surgery). Each RRC establishes and enforces requirements for training. Every one to five years, the appropriate RRC reviews training programs to ensure they are in compliance with ACGME’s rules.
The table 1 compares ABMS’s 24 Boards to ACGME’s 27 RRCs. The three differences between ABMS and ACGME are diagnostic radiology (which ABMS includes with radiation oncology), neurology (which ABMS combines with psychiatry), and transitional year (which is not relevant to ABMS).
To remain licensed, physicians must pursue continuing medical education (CME) throughout their careers. Often, CME is administered by specialty-specific societies (such as ACOG for gynecology and obstetrics). ACCME oversees this process by using “a voluntary self-regulated system for accrediting CME providers and a peer-review process responsive to changes in medical education and the health care delivery system.”17 ACCME standards are exacting and serve to try to ensure that education takes precedence at medical meetings that offer CME credits to physicians.
Concerns about patient safety during clinical trials in the late 1990s led to the creation of at least three organizations that attempt to evaluate the quality of research programs. Created in 2001, the Association for the Accreditation of Human Research Protection Programs (AAHRPP) “offers accreditation to institutions engaged in research involving human participants.”18 To accredit programs, the association “uses a voluntary, peer-driven educational model” that focuses on the “five domains of a highly developed human research program”: organization; research review unit, including institutional review boards; investigator; sponsor; and participant.18
The Department of Veterans Affairs (VA) in 2001 awarded a contract to the National Committee for Quality Assurance (NCQA) to “operate an accreditation program to ensure that VA medical centers are complying with VA and other relevant federal regulations designed to protect human subjects of research.”19 The VA Human Research Protection Accreditation Program (VAHRPAP) includes developing “standards for protecting human subjects of research” and assessing the extent to which VA medical centers “meet these standards through site surveys conducted by clinical researchers and research administrators.”19
In 2003, NCQA and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) formed the Partnership for Human Research Protection (PHRP) to “offer a new accreditation program that will seek to protect the safety and rights of participants in clinical trials and research programs in public and private hospitals, academic medical centers, and other research facilities in the United States and abroad.”20 PHRP standards address “institution responsibilities, institutional review board structure and operations, consideration of risks and benefits, and informed consent.”20
Although several organizations attempt to evaluate clinical programs, JCAHO is the most dominant for health care settings, particularly hospitals. JCAHO “evaluates the quality and safety of care for more than 16,000 health care organizations”—such as health care networks, ambulatory centers, home health services, and laboratories—in the United States.21 To earn or maintain accreditation, a health care organization “must have an extensive on-site review by a team of JCAHO health care professionals at least once every three years.”21
Frequently referred to as a “watchdog for the managed care industry,” NCQA also evaluates the quality of “individual physicians and medical groups.”22 To meet its mission of improving “the quality of health care,” NCQA attempts to generate “useful, understandable information about health care quality to help inform consumer and employer choice” as well as provide feedback that helps “physicians, health plans, and others to identify opportunities for improvement and make changes that enhance the quality of health care.”22
Seeking to reduce medical errors by 50 percent in five years, the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System in September 1999. This seminal report galvanized two organizations that were created the previous year. First, the Leapfrog Group “is an initiative driven by organizations that buy health care” that are working “to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans.”23 A “voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded,” the Leapfrog Group consists of a 160-member organization that spend an estimated $64 billion annually on health care.23
Second, the National Quality Forum (NQF) “is a private, not-for-profit membership organization established to develop and implement a national strategy for health care quality measurement and reporting.”24 With more than 200 members, NQF seeks “to improve American health care through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient.”24
In addition to these and other private efforts, the federal government—through the Centers for Medicare and Medicaid Services (CMS)—is pursuing several initiatives to improve health care. CMS “administers the Medicare program and works in partnership with the states to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.”25
AHA is the major hospital organization in the United States. Founded in 1898, AHA includes nearly 5,000 health care systems, networks, and hospitals. Although AHA attempts to represent the entire community, other organizations represent specialized facilities. For example, the National Association of Public Hospitals and Health Systems (NAPH) includes public entities; the Federation of American Hospitals (FAH) represents privately owned facilities; NACHRI and its public policy affiliate (National Association of Children’s Hospitals) represents “children’s hospitals, large pediatric units of medical centers and related health systems, including those that specialize in rehabilitative care of children with serious chronic or congenital illnesses;”26 and the American Association of Eye and Ear Hospitals—which consists of “the premier centers for specialized eye and ear procedures in the world”—is an example of an organization that represents the interests of specialty hospitals.27
Therefore, the hospital community in the United States is as fragmented as the physician community. This partition is not limited to physicians and hospitals, but applies to every aspect of American medicine—providers, facilities, and patients—and even the federal government.
In the United States, the federal government has a major responsibility for every aspect of health care. Because each state is different, this circle focuses on the federal government. To understand the federal government’s role in medicine, it is important to “follow the money.”28
The federal government consists of the executive (the White House and federal agencies), legislative (Congress), and judicial (the courts) branches. Congress is separated into the House of Representatives and the Senate; each chamber relies on a similar structure of committees and subcommittees to consider, improve, and approve legislation; in general, these panels are organized around the executive branch’s agencies.
From a financial perspective, congressional committees and subcommittees fall into two categories: those that provide entitlement funding (by statute, Congress must fund these programs) and those that provide discretionary funding (each year, Congress may or may not choose to appropriate money for these programs). In health care, the major entitlement programs are Medicare and Medicaid, which are run by CMS (which was previously the Health Care Financing Administration or HCFA). CMS is located in the Department of Health and Human Services (HHS).
In particular, Medicare supports graduate medical education (GME) through the direct graduate medical education (DGME) payment and the indirect medical education (IME) adjustment. The DGME payment covers the direct costs of medical education, such as salaries, stipends, educational facilities, and tools. The IME adjustment covers indirect costs, which includes allowances for the involvement of residents and supervising physicians in patient care as well as the severity of illnesses of patients requiring specialized services available only in teaching hospitals. In addition, disproportionate share hospital (DSH) payments are additional Medicare and Medicaid funding to help hospitals provide care for uninsured and low-income patients. Because physicians in teaching hospitals treat 72 percent of the uninsured, academic medicine is disproportionately affected as the number of people who lack health insurance or are underinsured increases.29
HHS also administers the majority of health-related discretionary programs, such as the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research or AHCPR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the Health Resources and Services Administration (HRSA). HRSA has traditionally offered grants and contracts that address issues of undergraduate medical education (www.hrsa.gov/grants/default.htm). Outside HHS, VA receives discretionary funding to operate health-related programs and conduct research through the Veterans Health Administration (VHA).
After completing his journey through The Inferno, Dante ventured from The Purgatorio to The Paradiso. While challenging, your tenure as a clerkship director will prepare you for continued success in medicine, where you—like Dante—can achieve professional and personal paradise.
American Board of Medical Specialty's 24 Boards and the Accreditation Council for Graduate Education's 27 Residency Review Committees
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Limited Glossary of Organizations and Terms in American Medicine
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