The Accreditation Council for Graduate Medical Education (ACGME) affects orthopaedic surgeons, especially those of us who work in residency and fellowship programs in many different ways. This article provides a primer on recent changes that are directly affecting orthopaedic surgical training today. For more details and the exact language of these changes, refer to the ACGME website (www.acgme.org).

Residency program directors
The ACGME approved focused revisions to the program requirements for graduate medical education (GME) in orthopaedic surgery in June 2015. These revisions will be effective July 1, 2016.

The revisions specify and expand the qualifications of the program director to include the following:

• a minimum of 4 years of clinical practice in the specialty, post residency and fellowship (IIA 3.d)
• a minimum of either 2 years of experience as an associate program director of an ACGME-accredited orthopaedic surgery program or 3 years of participation as an active faculty member in an ACGME-accredited orthopaedic surgery program (IIA 3.e)
• evidence of periodic updates of medical knowledge and skills to discharge the roles and responsibilities for teaching, supervision, and formal evaluation of residents (IIA. 3.f)

Information on specific examples or the criteria for evidence of knowledge and skills is not yet available.

Fellowship directors
There were no new regulations regarding fellowship directors. Currently, the ACGME regulations for fellowship director include requisite specialty expertise and documented educational and administrative experience acceptable to the review committee. They do not specify levels of experience or minimum time out of residency and fellowship. However, with the changes to the GME residency program, fellowship directors may well wonder whether further revisions may extend these changes to fellowship programs.

Fellowship directors are required to have a current certification in orthopaedic by the American Board of Orthopaedic Surgery.

Fellowship training
Multiple changes have occurred in the past several years that affect fellowship training and eligibility. The following changes are of particular note:

Independent fellowship programs—After July 1, 2013, no new independent fellowship programs would receive accreditation, although previously accredited programs would be able to maintain their status under a “grandfather” clause. These programs are not associated with a residency program; they are stand-alone programs within institutions that do not sponsor a core residency program. This change had the potential to affect several fellowships.

Among stand-alone programs are several in sports and hand, which must be ACGME-accredited due to the subspecialty certification. Stand-alone programs are also common in other orthopaedic specialties—except for tumor and trauma, which are generally associated with a core residency program.

The AAOS Board of Specialty Societies (BOS) Fellowship Match Committee has conducted surveys and attempted to gather information on the number of stand-alone programs, although obtaining accurate data is difficult. The committee has noted a decrease in ACGME-accredited programs based on match statistics.

DO and IMG applicants—When the common program requirements impact statement was revised, it specified that the prerequisite clinical education for entry into an ACGME-accredited residency program must be accomplished in a U.S. program accredited by the ACGME or in a Canadian program accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC).

The AAOS and all orthopaedic specialty organizations responded to this requirement revision. In addition, the AAOS sent representatives to the ACGME hearing on osteopathic physician (DO) applicants. Professional orthopaedic societies were concerned that the proposed changes and the growing number of osteopathic and international medical graduates (IMG) applying for fellowship programs could affect the match process.

The language that will apply in 2016 states that ACGME fellowship programs must take residents who completed an ACGME- or RCPSC-accredited residency program. The fellowship eligibility for those fellows beginning Aug. 1, 2016 (matched in 2015), requires the fellow to complete either an ACGME or RCPSC core specialty residency.

Except for hand fellowships, IMGs are eligible under the exception clause for ACGME-accredited Orthopaedic Surgery fellowships. Current rules apply to those American Osteopathic Association (AOA) programs that apply for ACGME accreditation by Aug. 1, 2016; DO applicants are permitted in ACGME-accredited fellowships as long as they are “rare.” DO graduates of AOA programs that have not applied for ACGME accreditation must meet the exception requirements.

The exception clause applies to individuals who completed a non–ACGME-accredited core residency. These individuals must demonstrate both clinical excellence and leadership comparable to their peers throughout the training and additional clinical or research training.

Hand fellowships—Different regulations apply to hand fellowships because applicants may be plastic surgery (PS), general surgery (GS), and orthopaedic surgery (OS) graduates. These regulations go into effect on Aug. 1, 2016. IMGs are eligible under the exception clause for ACGME-accredited OS fellowship programs, but not for PS and GS fellowships. Current eligibility rules apply to graduates from osteopathic programs that applied for ACGME-accreditation by Aug. 1, 2016. DO orthopaedic surgery graduates from these programs are permitted in fellowship programs. Otherwise, DO applicants must meet the exception requirements.

Allopathic and osteopathic single accreditation system
On Feb. 26, 2014, the ACGME and the American Association of Colleges of Osteopathic Medicine agreed to a single accreditation system for all U.S. GME programs. The implementation timetable can be found on the ACGME website. AOA-accredited programs may now apply for ACGME accreditation (effective July 1, 2015). Institutions must apply for ACGME-accreditation prior to program application and will be listed on the ACGME website with pre-accreditation. Residents in these programs will be eligible for ACGME-accredited orthopaedic surgery fellowships as previously described.

The ACGME will conduct site visits to AOA programs, and those that do not achieve initial accreditation by June 30, 2020, will lose their AOA accreditation. With the single accreditation system, the AOA has nominated Richard F. Howard, DO, to the ACGME Resident Review Committee.

Impact of changes
The main question is how are all these rules affecting DO and IMG applicants? When the new regulations began to take effect in 2015, a stark difference could be seen between match statistics for 2014 and those for 2015 (Fig. 1). One concern is that this could drive applicants to seek fellowship positions outside of the organized match process. This could disrupt the current match process if fellowship programs become frustrated and seek applicants outside the match. Or, programs that are not part of the current match process could establish another way to find fellows.

The AAOS and orthopaedic specialties have worked hard to ensure the viability of the fellowship match process and have a vested interest in keeping abreast of these changes. The ACGME, especially Pam Derstine, executive director of the Orthopaedic Surgery RRC, has been actively educating all those involved in GME of these rules and regulations. We are grateful for their assistance.

Lisa K. Cannada, MD, is associate professor of orthopaedic traumatology at the Saint Louis University School of Medicine in St. Louis.