In Reply to Buser and to Shannon

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Drs. Buser and Shannon imply incorrectly that my article assumes osteopathic programs will be denied Accreditation Council for Graduate Medical Education (ACGME) accreditation solely on program size. What the article does emphasize is that if an American Osteopathic Association (AOA) program is to achieve full ACGME compliance, it must meet the required minimum number of residents, either in the present or the future. The challenge for osteopathic GME programs is to consider the financial, educational, and clinical changes that need to occur to achieve compliance.
The AOA standards are silent on companion programs. Unlike Dr. Buser, the article makes no assessment whether it is easy or hard to find affiliations. Rather, it points out that a companion requirement is evident and the challenge for DO programs is to identify affiliate sites, generate program letters of agreement, and consider the lost reimbursement in having residents rotating at outside hospitals.
Dr. Buser disagrees with the linkage between the growth of primary care in AOA programs and GME unification between 2013 and 2015. Dr. Buser cites an AOA 7.5% annual growth in new training programs since 2008. Responding is complicated by ambiguity. The AOA had a one-year increase in programs of 3.9% in 2009,1 4.4% in 2010,1 and 6.7% in 2011.2 Dr. Buser’s percentage includes fellowship programs and residencies, while the data mentioned in the article are specific to program and resident numbers in family and internal medicine—with a small sidebar to general surgery.
Dr. Buser does not agree that there is an inflation of AOA GME positions. An examination of GME programs in family practice and the traditional internship bear this out. In 2015, family medicine had 3,874 AOA-approved positions and, as a three-year residency, could offer up to 1,291 PGY-1 positions in the AOA Match.3 In the 2015 AOA Match,4 917 funded positions (71%) were available and only 549 (60%) of them filled. The AOA reported 1,232 internship positions; 497 (40%) were funded and only 191 (38%) filled. When high numbers of approved AOA positions go unfunded and unfilled over an extended period of time, it appears justified to claim evidence of inflated numbers of functional AOA-approved positions.
My reading of the standard for transitional-year programs was that the sponsoring institution needed two ACGME programs beyond the transitional-year program. It has been pointed out by Drs. Buser and Shannon and verified by an ACGME representative that this interpretation is incorrect and that only one additional ACGME program is needed. The ACGME is initiating a focused revision and rewriting this standard to improve clarity. I want to thank Drs. Buser and Shannon for this correction and their comments on this article.
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