The Elusive Goal of Accountability in Graduate Medical Education

Repeated calls for greater accountability of graduate medical education (GME) have been issued in recent years. In this context, Kenneth Ludmerer's Let Me Heal examines the issue of duty hours limits and paints a picture of failed accountability. The ways in which duty hours regulations have failed are discussed, pointing toward a need to focus on goals and outcomes (such as patient safety) rather than process (such as schedules and shift length). This Commentary considers key issues-who should be accountable, for what, and to whom?-and proposes a potential path for achieving accountability in GME. The author draws from consensus reports published by the Josiah Macy Jr. Foundation and the Institute of Medicine to outline the case for why the U.S. system of GME should be accountable to the public, to individual patients, and to the residents and fellows being educated. Domains of accountability include graduating competent physicians, producing the right workforce, and ensuring an efficient and cost-effective training process that is designed to protect patients. In addition, the author argues that GME should be accountable for providing trainees with reasonable working conditions and compensation. Key requirements for achieving meaningful GME accountability are proposed, including (1) a more effective partnership with the public; (2) explicit goals and assigned responsibilities, reflecting reasonable expectations of what GME can accomplish; (3) reliable metrics for GME outcomes; and (4) a governance system that provides coordination and has the authority to effect changes.