The process of medical education and surgical training in the United States is overseen by an interconnected group of organizations. Each of these organizations has their specific focus; however, the common theme is continuous process improvement encouraged by intermittent external review (Table 2–1). The ultimate goal is the provision of a consistent, qualified, and professional workforce for medical care in the United States.

Medical Student Education

The Liaison Committee on Medical Education (LCME) is the group that provides accreditation for medical schools in the United States and Canada. Accreditation is the process of quality assurance in postsecondary education that assesses whether an institution meets established standards. Accreditation by the LCME is effectively necessary for schools to function in the United States. Without accreditation, the schools cannot receive federal grants for medical education or participate in federal loan programs. Graduation from an LCME-accredited school enables students to sit for medical licensing examinations (the USMLE) and to achieve licensure in most states around the country. Graduation from an LCME-accredited medical school is also necessary for acceptance into an ACGME-accredited residency program (see below) for graduates of US medical schools. The authority for the LCME to provide this accreditation is delegated by the United States Department of Education in the United States and the Committee on Accreditation of Canadian Medical Schools (CACMS) in Canada.

Each accredited medical school is reviewed annually for appropriateness of their function, structure, and performance. Formal site visits are conducted periodically with more in-depth review and reaccreditation at that time. The usual period of full accreditation is 8 years. At the time of this in-depth accreditation visit, and in the intervals between, the LCME works to disseminate best practices and approve the overall quality of education leading to the MD degree.

Graduate Medical Education

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of post MD medical training programs within the United States. Accreditation is accomplished through a peer review process based on established standards and guidelines. The member organizations of the ACGME as an accrediting group are the American Board of Medical Specialties (ABMS), the American Hospital Association (AHA), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies. The ACGME oversees a variety of graduate medical education programs in specific specialties. These ACGME-accredited residency programs must adhere to the ACGME common program requirements that apply to all residencies, as well as specific program requirements that apply to each training program. The ACGME also accredits institutions to house the residency training programs. There are thus also institutional requirements that must be met for overall accreditation of the institution to house training programs.

The ACGME has identified six general competency areas that must be addressed during every graduate residency training program (Table 2–2). The specific application of these competency areas varies widely among training programs. However, each rotation of each residency must include attention to, and assessment of, progress in fulfilling the general competency requirements.

The review and accreditation of specialty residency programs is undertaken by a committee specific for that field. In surgery, the group is the Residency Review Committee for Surgery (RRC-S). The RRC-S assesses program compliance with accreditation standards both at the common program requirement level, and at the program specific level. Programs are typically fully accredited on a five year cycle, with annual updates and questionnaires in the interim. Early site visits can be triggered by a variety of events including significant changes in the program or its leadership. The Residency Review Committees also control the number of positions that each program is accredited to have. This effectively sets the maximum number of graduates that can finish from a given training program in any given year.

American Board of Surgery

The American Board of Surgery (ABS) is an independent, nonprofit organization with the purpose of certifying individual surgeons who have met defined standards of education, training, and knowledge. The distinction between the ACGME and the ABS is that the ACGME accredits training programs, while the ABS certifies individuals. This distinction is similar for specialty boards in other disciplines as well. The ABS also recertifies practicing surgeons, and is making a fundamental philosophical change from periodic retesting for recertification to a more continuous maintenance of certification (MOC) plan.

The ACGME and the specialty boards interact. The success of individuals in achieving board certification is considered an important measure of graduate medical education program success, and the measures that can be required of an individual for board certification must somehow also reflect the education that is offered to them through their graduate medical education. Thus though these entities have different purposes, they must, optimally, mesh their efforts constructively.

Board certification within a defined period after completing residency is necessary for privileging to perform surgery in many hospitals in the United States. Thus the most straightforward route into surgical practice in the United States includes graduation from an LCME-accredited medical school, completion of an ACGME-accredited residency training program, and satisfactory completion of the Qualifying Examination (written boards), and Certifying Examination (oral boards) of the American Board of Surgery.

There are other entry points into surgical practice in the United States, most prominently by physicians who have graduated from medical schools in countries outside the United States and Canada. These graduates can be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). Once an individual graduate has been certified by the ECFMG, then he or she is eligible to train in an ACGME-approved residency training program, and can thus be eligible for board certification.

American College of Surgeons

The American College of Surgeons (ACS) is a scientific and educational association of surgeons whose mission is to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS has members, known as fellows, who are entitled to use the letters FACS after their name. Membership as a fellow implies that the surgeon has met standards of education, training, professional qualifications, surgical competence, and ethical conduct. However, despite these requirements, the ACS is a voluntary professional membership group, and does not certify individuals for practice. The ACS does sponsor a wide variety of educational and professional support programs both for practicing surgeons and trainees. In addition, they have membership categories for surgeons in training (Resident Membership) and students (Medical Student Membership), and for those surgeons who have completed training but have not yet met all the requirements for fellowship (Associate Fellow). The ACS also engages in important advocacy roles on behalf of patients and the surgeon members.