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Modification of Requirement Regarding Additional Training Programs for PCCM and CM Fellowship Programs

 

On behalf of the Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD) Board of Directors, we thank you for your continued support and response to important surveys that help us shape GME policy as a community.

The APCCMPD is providing our constituents with the outcome of our efforts to modify the Accreditation Council on Graduate Medical Education (ACGME) additional program requirement for pulmonary/critical care medicine (PCCM) and critical care medicine (CCM) fellowships.

The requirement currently reads "Located at the primary clinical site, there should be at least three ACGME-accredited subspecialty programs from the following disciplines: in cardiovascular disease, gastroenterology, infectious diseases, nephrology, or pulmonary disease" (only two of that list are needed for PCCM programs, because pulmonary serves as one). 

Issue Brief

In September of 2014, the Association of Subspecialty Professors (ASP), the Association of Program Directors in Internal Medicine (APDIM), and the Alliance for Academic Internal Medicine (AAIM) asked the APCCMPD BOD to provide an opinion on removing the aforementioned requirement. After surveying PCCM and CCM Program Directors. In a letter to the ACGME the APCCMPD concurred with national stakeholders that the requirement should be deleted or clarified in an FAQ for the following reasons:

  1. Institutions considering the creation of a new PCCM or CCM fellowship program may not grasp the intended distinction between “should” and “must” or between “sponsor" and “located at”. 
  2. This confusion might inadvertently discourage institutions that wish to create new PCCM or CCM fellowship programs.
  3. CCM is uniquely multidisciplinary and its practice requires clinical expertise beyond the listed fellowships. Clinical expertise should not necessitate training programs in those fields.
  4. The existence of a core Internal Medicine (IM) and surgery residency programs would serve as a surrogate marker to the institution’s commitment and culture of teaching.

ACGME Response

The ACGME agreed to consider removing the requirement as long as replacement language could be provided that would meet the “intent” of the current requirement. The ACGME requested the APCCMPD and CCSC Task Force (CHEST, ATS, and SCCM) to collaborate on draft such language.

In May of 2015, the APCCMPD and the CCSC Task Force proposed language to the ACGME. The ACGME Review Committee for Internal Medicine (RC-IM) expressed their gratitude for our continued dialogue and appreciated the stakeholders’ recommendation; however, it found the new language problematic (see ACGME response for full details).  Furthermore, the RC-IM noted that not all PCCM and CCM program directors are in support of removing the requirement and in fact, a significant percentage of PCCM and CCM program directors are not in favor of removing the requirement (35% and 22%, respectively).

Ultimately the ACGME decided to keep the requirement as is, but make explicit the “intent” of the requirement. The following FAQ was developed:

Program Requirement: Located at the primary clinical site, there should be at least three ACGME-accredited subspecialty programs from the following disciplines: cardiovascular disease, gastroenterology, infectious diseases, nephrology, or pulmonary disease (PR I.A.2) 

Question: What is the intent of requiring that there be three additional accredited internal medicine (IM) subspecialty programs located at the primary clinical site?

Answer:  The intent of this program requirement is to ensure that pulmonary disease and critical care medicine (PCCM) and critical care medicine (CCM) fellows are educated in a multidisciplinary clinical environment where they have the opportunity to interact with and learn from other subspecialty fellows and faculty members who are committed to graduate medical education and providing care to critically ill patients. While this intention is best realized when there are other IM subspecialty programs at the primary clinical site, the program can also meet this end by ensuring that there are meaningful, substantive and collaborative interactions between the PCCM/CCM fellows and other IM subspecialists. Although PCCM and CCM programs must have ABIM certified clinical faculty in nephrology, gastroenterology, cardiology, infectious disease, hematology and oncology who participate in the program (PR II.B.8.a.), their presence in and of itself will not ensure compliance with the intent of this requirement. An example that would meet the intent (if three internal medicine subspecialties from the list above are not located at the primary clinical site), would be if an infectious disease faculty member regularly participated and interacted with the PCCM/CCM fellows in ICU multidisciplinary rounds; similar meaningful participation by other subspecialists would also be expected. Participation of other subspecialists at formal teaching conferences as the sole or major interaction with PCCM/CCM fellows would not necessarily fulfill the intent of this requirement. At the time of application, new programs without three other subspecialty programs at the primary clinical site will need to describe how the intent of the requirement will be fulfilled. 

NEW QUESTION ON PCCM/CCM APPLICATION 

The following question will be added to the PCCM application:

If at the primary clinical site there are fewer than two ACGME-accredited programs in the noted internal medicine subspecialties (cardiovascular disease, gastroenterology, infectious diseases, nephrology), then describe how this program will ensure that its fellows are educated in a multidisciplinary clinical environment with the opportunity to interact with and learn from other subspecialty fellows and faculty members as they provide care to critically ill patients. 

A similar question will appear in the CCM application, but the question will read “if at the primary clinical site there are fewer than three ACGME-accredited programs…”

The ACGME noted that noncompliance with only this particular requirement has not led to an adverse action in the past. In fact, the RC-IM has accredited four CCM programs that did not meet the aforementioned requirement. The RC gave these programs a citation because the requirement had not been met and because an acceptable alternative to the requirement had not been provided or demonstrated.  

The FAQ is posted on the ACGME PCCM FAQ and ACGME CCM FAQ webpage.