ACGME Statement on Early Graduation from US Medical Schools and Early Appointment to the Clinical Learning Environment

The ACGME has issued an updated statement that supercedes all other guidance regarding early graduation from US allopathic and osteopathic medical schools and early appointment to the clinical learning environment.

Many health care facilities in the United States are facing or will face significant challenges as they respond to the COVID-19 (SARS COV2) pandemic. Through public information, the ACGME has become aware that some US allopathic and osteopathic medical schools are hoping to assist these facilities by planning for the early graduation of their fourth-year medical students to facilitate graduates’ participation in the pandemic response. Except in unusual or exigent circumstances, the ACGME does not recommend the early graduation of medical students.

The ACGME recognizes that most medical students will graduate with binding match commitments to enter ACGME-accredited residency programs in 2020 and 2021. Most graduate medical education programs are currently encountering either increasing clinical volume related to the COVID-19 pandemic, or are sponsored by institutions that have self-identified as being in Emergency Pandemic Status. Institutions such as these are ill prepared to offer the comprehensive orientation and training in Personal Protective Equipment (PPE), and direct supervision required for new residents at the start of their residency. Furthermore, and well documented in the lay press, these same medical students have been removed from fourth-year clerkships in these same institutions due to inadequate supplies of PPE. Thus, it is the opinion of the ACGME that except in unusual or exigent circumstances, graduating medical students should matriculate to their PGY-1 position at the intended National Residency Match Program (NRMP) start date, or other date that is nationally determined to be the beginning of the 2020-2021 academic year.

The above notwithstanding, Sponsoring Institutions in exigent circumstances have asked the ACGME to clarify the circumstances under which early graduates may participate as residents or other health-related workers.

To be considered a resident in a medical or a medical-related field, an early 2020 medical school graduate must be appointed to an ACGME-accredited program. While not the purview of the ACGME, it must be noted that there are serious ramifications to early appointment (Centers for Medicare and Medicaid Services (CMS) reimbursement for direct graduate medical education (DGME)/indirect medical education (IME) and Match participation agreements, among many others). The ACGME urges medical schools and graduates to seriously consider these ramifications prior to initiating early graduation for any medical students.

Detailed Guidance on Early Graduation from US Allopathic and Osteopathic Medical Schools and Appointment to ACGME-Accredited Programs

Early US (Domestic, non-IMG) Allopathic and Osteopathic Medical Graduates Scenarios:

1. Matched or accepted medical student starts planned appointment
   1. If the program would be within its approved complement, appointment in an ACGME-accredited program may proceed.
   2. If the program would not be within its approved complement, Review Committee approval of a temporary complement increase must be obtained prior to appointment in an ACGME-accredited program. Approval of temporary complement increases, when required, must also be obtained by programs of Sponsoring Institutions that have declared Pandemic Emergency Status.
   3. Approval of temporary complement increases will terminate with the onset of the 2020-2021 academic year.

2. Early appointment to an ACGME-accredited program other than the program of a matched/planned residency appointment

This is a highly undesirable path. There are a number of issues external to the ACGME that need to be considered by the Sponsoring Institution seeking to appoint an individual to a program other than the program of that individual’s matched/planned residency appointment, as well as by the prospective appointee. While all the issues have not been explored, the following three are key:

• potential violations of Match participation agreements;
• the implications for first specialty Initial Residency Period (IRP) rules by CMS in the matched/committed program; and,
• the uncertain applicability of this experience to initial board certification.

The above issues aside, if programs and appointees wish to proceed, the following expectations apply:

1. If the program would be within its approved complement, appointment in an ACGME-accredited program may proceed.
2. If the program would not be within its approved complement, Review Committee approval of a temporary complement increase must be obtained prior to appointment in an ACGME-accredited program. Approval of temporary complement increases, when required, must also be obtained by programs of Sponsoring Institutions that have declared Pandemic Emergency Status.
3. Approval of temporary complement increases will terminate with the onset of the 2020-2021 academic year.

1. US allopathic or osteopathic medical school graduate participates in pandemic response as a non-GME “medical worker”

The ACGME does not recognize these non-GME medical workers as residents in ACGME-accredited programs. These medical workers must not be viewed as “other learners.” Residents must not be responsible for supervision of medical care directly provided by these medical workers. If these medical workers are deployed in teams that include residents/fellows, they must support the team’s provision of care. Examples of such support would include scribes, IV teams, transport, or services that support the efforts of the team in caring for patients. An example of what would be considered an “other learner” would include functioning as a PGY-1, providing direct patient care.

The ACGME has no discrete role in this circumstance other than to be assured by the Sponsoring Institution and relevant programs that the presence of these individuals does not compromise the Sponsoring Institution’s or its programs’ compliance with ACGME requirements regarding supervision, clinical and educational work hours, and resident/fellow and patient safety, including appropriate training in and provision of infection protection that is appropriate for the clinical setting and situation, consistent with the previously issued guidance from the ACGME on supervision, PPE, education and training, and work hours.

4. Unmatched US (Domestic, non-IMG) Allopathic and Osteopathic Medical Graduates, and International Medical Graduates with valid ECFMG certification Scenarios:
   
   ACGME-accredited Sponsoring Institutions that permit programs to appoint unmatched/uncommitted graduates, consistent with their programs’/Sponsoring Institutions’ match participation agreements, must offer at least 1 year of appointment in an ACGME-accredited program (if eligible per ACGME requirements). Any such appointments must be reviewed and approved in advance by the Sponsoring Institution’s Graduate Medical Education Committee (GMEC). Enrollment in preliminary year positions, categorical positions, and positions in Transitional Year programs may be appropriate in this circumstance.
   
   
   1. If the program would be within its approved complement, appointment in an ACGME-accredited program may proceed.
   2. If the program would not be within its approved complement, Review Committee approval of a temporary complement increase must be obtained prior to appointment in an ACGME-accredited program. Approval of temporary complement increases, when required, must be obtained by programs of Sponsoring Institutions that have declared pandemic emergency status (Stage 3).