“You can’t take over the world without a good acronym” - C.S. Wooley

As we start our careers in medicine, both in medical school and residency, we are confronted with a seemingly endless array rules and regulations issued by a mass of seemingly faceless organizations.  The purpose of this page is to acquaint the reader with the nuts and bolts of the organizations and rules and regulations that govern our education.  

In addition, many of these organizations have a number of opportunities for leadership. A bit of knowledge about who these organizations are can help you (as a medical student, resident, junior faculty) decide where and how you want to get involved.  

There is a lot of information here, so the page is divided into 2 major subsections: 

Educational - Here we will cover many of the acronyms, rules, and regulations that govern medical student and resident education (SLOEs, III, Duty Hours, etc)

Organizational - Here we will cover a sampling of major organizations that have an impact on Residents and Medical Student education as well as organizations with a mission in the specialty of Emergency Medicine 

SLOE

What is a SLOE?

A SLOE is a Standardized Letter of Evaluation used for application to EM residency programs. A SLOE is an “Evaluation” and not a “Recommendation,” as SLOEs are used to portray an honest assessment of a student’s clinical ability, intelligence, and personality.

Who writes SLOEs?

Many SLOEs are “Group SLOEs” produced by a combination of Clerkship and Residency Leadership. These are experienced letter writers who have a grasp of the whole field of applicants. Group SLOEs are highly valuable and are often heavily weighted relative to the remaining ERAS application. SLOEs can also be written by single faculty authors, although they tend to be less useful.

What goes into a SLOE?

• Background Information: Includes degree of contact with the applicant, month rotation took place, and grade relative to the prior academic year. This comparison is important: Honors at an institution where 10% Honor is very different than the same grade where 50% Honor.
• Qualifications for EM: This compares personality traits and clinical ability to other EM-bound peers by dividing the group into thirds. Any “Below peers – Lower 1/3” score must be justified in the comments section.
• Global Assessment: All applicants are ranked and compared to ranks used in the previous academic year. Similar ranks are used to predict the applicant’s place on your program’s Rank Order List.

1. Top 10%
2. Top 1/3
3. Middle 1/3
4. Lower 1/3**

• Written Comments: This is the art of the SLOE. SLOE writers, especially Clerkship Directors, have an obligation to advocate for their students while realistically portraying their abilities and likelihood of success in training for program directors. I call this approach “optimistic realism.” It is also important to give the reader a sense of the student’s personality, work ethic, and maturity. All Lower 1/3 ranks require explanation, but try to expand upon the student’s responsiveness to feedback and potential for improvement. Over time, you will get a sense for lingo used by specific writers and programmatic trends. Read between the lines and look for buzzwords that may be used to elude to potential student issues.

**CORD (the governing body for the SLOE) recommends that all programs adhere as closely to the 1/3s as possible, though there is still significant variability. CORD surveys have shown that applicants in the Lower 1/3 usually still match.

How many SLOEs does an applicant need?

According to CORD Program Director surveys, 80% of programs require one SLOE to grant an interview and 95% required at least two SLOEs by Interview Day in order to rank applicants. Students should have a SLOE for each rotation they complete, and should take care to reserve letter slots for late Away Rotations. Having a Home or Away Rotation without an accompanying SLOE will raise questions. ERAS can accommodate a maximum of four letters, so strategy is important when choosing letter writers. Since SLOEs are comparative, they are written and released in batches. The first, large batch is uploaded to ERAS by October 1st, with a smaller group of letters at the end of October Away Rotations. 

Grand Rounds and III (Individualized Interactive Instruction)

Why do I have to go to Grand Rounds?

The ACGME requires Emergency Medicine residency training programs to provide “an average of at least 5 hours per week of planned didactic experiences.” IV.A.3.c)  Where these didactic experiences should be comprised of “administrative seminars, journal review,… morbidity and mortality conferences, and research seminars.”  Furthermore, the ACGME requires that residents attend at least 70% of the planned didactics.

But, why can’t I just listen to podcasts?

Because listening to podcasts alone is not, in the eyes of the ACGME, an equivalent replacement for the regularly planned didactics described above.  The ACGME does allow for Individualized Interactive Instruction (III), often referred to as ‘asynchronous education’ by many, to replace up to 20% (1 hour per week) of planned didactic experiences.

So you’re saying there’s a chance that I can listen to podcasts through this III thing?

Maybe.  To qualify as III, an asynchronous educational activity needs to meet 4 criteria:

1. The program director must monitor resident participation
2. There must be an evaluation component.
3. There must be faculty oversight.
4. The activity must be monitored for effectiveness.

These criteria are a bit on the vague side, but the ACGME goes on to emphasize that the must be some component of interaction between faculty and resident built into the educational experience.  And, the ACGME specifically states that the “use of audio, video, or podcasts alone constitutes passive learning and is not considered interactive learning.”

So, you could listen to a podcast, watch a video online, or read a textbook or blog post, but to qualify as III, you would also have to (for instance) subsequently participate in an online discussion with faculty/other residents or take part in some other equivalent interactive experience.

CORD

What is CORD?

While CORD stands for the Council of Emergency Medicine Residency Directors, the organization represents the broader training mission of emergency medicine. Medical student and resident educators, Clerkship and Residency leadership, and Residency Program Coordinators all fall under the auspices of CORD. While CORD is run out of ACEP’s administration, they were born out of SAEM and currently liaise with several national organizations (AAEM-RSA, EMRA, ACEP, AAMC).

What is the mission of CORD?

• Raise the quality of emergency medicine educational programs
• Assure that emergency medicine educational programs anticipate and adapt to the needs of the workforce
• Exercise its voice to influence issues impacting emergency medicine education
• Collaborate with other organizations on education-related initiatives
• Foster educational scholarship and research in emergency medicine

What does CORD offer?

• CORD Academic Assembly: National conference held in March or April every year, specifically focused on innovation and research in medical education as well as administrative best practices. They also host the National Resident/Faculty CPC Competition. While much of the conference is open, you can choose to attend content in specific tracks (Resident Track, Navigating Academic Waters, Clerkship Directors in Emergency Medicine (CDEM), Best Practices, EMARC: Program coordinators)
• Medical Education Research Certificate (MERC) Program: Joint venture with AAMC in which participants complete a mentored education research project over a series of workshops in order to promote medical education research and foster collaborative research among the national community of EM educators. 
• Taskforces for various hot topics in medical student and resident education that help establish national standards and recommendations (ex: SLOE Taskforce, Medical Student Advisement Taskforce, Patient Experience Taskforce, Transition of Care Taskforce, etc.).
• Discussion forums and listserves for to share problems and ideas
• Free educational materials including traditional Oral Boards and eOral Boards preparation as well as simulation cases
• Resources for New Accreditation System and EM Milestone Assessment Tools

Why should I care about CORD?

CORD helps create a continuum of Undergraduate and Graduate Medical Education in EM. Whether you participate in CORD or not, they do represent the national voice of emergency medicine education and their policies will impact you. If you’re considering a career in medical education, the CORD Academic Assembly is an opportunity to immerse yourself in a community of educators, network, and get academic career development tips from experts.

SAEM

Formed in 1989 with the merge of University Association for Emergency Medicine (UAEM) and Society for Teachers in Emergency Medicine (STEM). SAEM focuses primarily on academic factors in the realm of Emergency Medicine, primarily aiming to further research and education in the field. It does this by fostering leadership, mentoring and networking between academic EM physicians. They also offer significant grants and funding for research and innovations in EM. The organization also consists of many subgroups (academies and interest groups) which provide further information, networking and leadership opportunities for particular fields within the realm of EM.

SAEM is responsible for publishing the journals Academic Emergency Medicine and the newly minted AEM Education and Training

Vision: To be the world's premier organization for developing academic leaders in education and research and for creating and disseminating content with the greatest impact on emergency care

ACEP

Founded in 1968 with the goal to educate and train emergency physicians and allow EM physicians the resources needed to provide care. Members are required to have:

1. Completed an ACGME-approved emergency medicine residency
2. Completed an AOA-approved emergency medicine residency.
3. Been certified by any other emergency medicine certifying body recognized by ACEP
4. Been practicing as emergency physicians since before 2000 (a/k/a "Legacy" physicians)

In practice, ACEP is the largest emergency medicine organization and focuses on trends in the healthcare landscape, working to maintain the interests of Emergency Physicians both politically, as well as educationally. They are the primary body for national advocacy in the field of EM. They are responsible for publishing practice guidelines which help define the scope and expectations of Emergency Physician. They also set CME guidelines for practicing physicians. They foster research through a partnership with Emergency Medicine Foundation (EMF), which offers education on conducting research in the field of EM, as well offering grants for selected projects.

ACEP is also the publishing body for the journal Annals of Emergency Medicine and ACEPnow magazine

ACEP is also the umbrella organization for the Emergency Medicine Residents Association (EMRA) which offers significant educational resources for both residents and medical students. EMRA also offers leadership and mentoring opportunities both globally in EM as well as in specific fields or niches in EM. EMRA is responsible for publishing EM Resident magazine and multiple educational supplements (such as antibiotic guide, PressorDex, etc.)

ACEP Mission Statement - The American College of Emergency Physicians promotes the highest quality of emergency care and is the leading advocate for emergency physicians, their patients, and the public.

Vision Statement

• Emergency medicine is recognized and valued as an essential public service.
• Patients seeking emergency care are treated by board certified emergency physicians who are supported in their practices with all resources necessary to provide the highest quality medical care.
• Emergency physicians practice in an environment in which their rights, safety, and wellness are assured.
• All patients have health care coverage that ensures access to emergency services. Legally mandated health care services are fully funded.
• Resources for education and training of emergency physicians are sufficient to meet the workforce needs of the specialty.
• Emergency physicians are recognized and valued for their commitment to high quality patient care, teaching, leadership, research, and innovation.
• All emergency physicians are members of the American College of Emergency Physicians.

AAEM

A smaller, newer organization, founded in 1993 with the aim of protecting the interests of the individual Emergency Physician. Specifically, the group aims to preserve fairness and transparency in the field and avoiding corporate/organizational influence on the Emergency Physician. They are responsible for advocacy at a national level on multiple issues including clinical care, litigation reform, and compensation. They also offer continuing medical education (CME) as well as leadership and educational opportunities within the organization.

AAEM is responsible for publishing the Journal of Emergency Medicine

 AAEM Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles:

1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.
2. The practice of emergency medicine is best conducted by a specialist in emergency medicine.
3. A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).
4. The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM.
5. The Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care. Such an environment includes provisions for due process and the absence of restrictive covenants.
6. The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient.
7. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members.
8. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Vision statement

A physician's primary duty is to the patient. The integrity of this doctor-patient relationship requires that emergency physicians control their own practices free of outside interference.

We aspire to a future in which all patients have access to board certified emergency physicians.

The Principles

1. The ideal practice situation in emergency medicine affords each physician an equitable ownership stake in the practice. Such ownership entails responsibility to the practice beyond clinical services.
2. Emergency physicians should have control over their professional fees and should not engage in fee-splitting.
3. The role of emergency medicine management companies should be to help physicians manage their practice. The practice should be owned by and controlled by its physicians and not by a management company.
4. Medical societies should actively encourage the creation and enforcement of statutes prohibiting the corporate practice of medicine.
5. Medical societies should not accept financial support from entities that do not adhere to the above principles.

Emergency medicine specialty societies should work towards the goal of establishing a workforce sufficient to ensure that all emergency departments in the United States and its territories are staffed by emergency physicians certified by either the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.

ACGME

ACGME stands for the Accreditation Council for Graduate Medical Education. It is a not-for-profit, 501(c)(3) organization that sets national standards for graduate medical education in the US (residency and fellowships). Practically, this means that it confers national recognition and accreditation of graduate medical education programs. ACGME accreditation assures that the program meets the quality standards of the specialty practice (like EM, or pediatrics, for example). More information about the ACGME can be found here: http://www.acgme.org/What-We-Do/Overview

RRC

RRC stands for residency review committee. RRCs propose requirements for residency program accreditation, as well as ensure compliance with standards for individual specialty programs (like EM, surgery, etc). RRCs always maintain resident representation as well as higher level representation on the committee. The RRCs fall under the banner of ACGME, and there is an RRC for each subspecialty that ensures that the given subspecialty programs are maintaining minimum standards. The RRC then reports to ACGME for accreditation and maintenance of accreditation. More information about review committees can be found here: http://www.acgme.org/About-Us/Committees-and-Members-Selection-Process

LCME

The LCME, or Liaison Committee on Medical Education, is the body that accredits medical education programs leading to the MD degree in the United States and Canada. It functions by publishing a list of standards that all medical schools must adhere to, and conducting periodic reviews (“site visits”) to ensure schools meet these standards. In theory, LCME accreditation is voluntary from the perspective of a medical school (it’s possible to award an MD degree without it), however most residency training programs and state medical boards require or strongly prefer LCME accreditation, and so in practice, every US medical school operates by these standards.

The LCME is made up of representatives from both the AAMC (Association of American Medical Colleges) and the AMA (American Medical Association). These parent organizations set the political and philosophical agenda for medical education and academic medicine, and then the LCME translates this into specific standards and conducts periodic reviews to hold medical schools accountable.

If you’re reading this after graduating medical school, the LCME has very little practical importance to your life as a resident and practicing physician – except as it applies to your teaching interactions with medical students. Every resident will occasionally function as an evaluator of medical students, and these evaluations usually ask you to rate the student on a variety of “competencies.” This framework for evaluations is required by the LCME. (Individual schools have some latitude on what they consider core competencies, though many tend to mirror either residency competencies or Entrustable Professional Activities as defined by the AAMC).

From an education leadership perspective, it’s important to understand that medical school administrators use LCME standards as the framework for their curriculum, and any curricular innovations that impact medical students should follow these guidelines. If you are working on a project that involves medical students, understanding how your specific institution translates LCME standards into concrete competencies and learning objectives is crucial to pitching your idea. Additionally, many medical schools will form various curriculum review committees in preparation for the periodic LCME site visits. This can be an opportunity for junior faculty to get involved in medical school administration and program development.  More information about the LCME can be found here: http://lcme.org/about/

CLER

CLER stands for Clinical Learning Environment Review, which is a program implemented by the ACGME to evaluate each ACGME clinical site in between accreditation visits on six specific topics, including patient safety; health care quality; care transitions; supervision; duty hours and fatigue management and mitigation; and professionalism. Each institution that undergoes a CLER visit gets a report from the committee on how the clinical site is performing on each of the above topics, along with areas for improvement. ACGME implemented CLER in response to the rapid changes each health care system undergoes and it acts as a way to give programs periodic feedback outside of an official accreditation visit.

NAS

The Next Accreditation System (NAS) was implemented in July 2013 by the ACGME as a new method for residency program accreditation.

Prior to the NAS, each specialty’s RRC would visit every program every 3 to 5 years (depending on how the last site visit went).  Each site visit required a significant amount of work on the part of the residency program being surveyed, primarily in preparation of documentation to support that the program was meeting ACGME Program Requirements (Emergency Medicine Program Requirements: https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/7/Emergency%20Medicine).

The NAS was developed with three primary goals:

1. To enhance the ability of the peer-review system to prepare physicians for practice in the 21st century
2. To accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes
3. To reduce the burden associated with the previous structure and process-based approach (and allow for more innovation within programs)

• For more information see Nasca, et al. The Next Accreditation System – Rationale and Benefits. N Engl J Med. 2012 Mar 15; 366(11):1051-6.

So, that sounds great, but what is the difference between NAS and the old system?

With NAS, ACGME was attempting to move from a more process-based accreditation system (how do you teach your residents) to a clinical competency-based system (what have your residents learned).  This was done by the introduction of Milestones.  Each specialty developed their own set of Milestones.  Emergency Medicine milestones, developed in collaboration between ACGME and the American Board of Emergency Medicine (ABEM) can be found here:  https://www.abem.org/public/docs/default-source/migrated-documents-and-files/em-milestones.pdf?sfvrsn=6

Also, with NAS, the ACGME moved away from episodic site visits to annual data collection.  Twice a year, each resident is evaluated on his or her specialty-specific milestones and this data is submitted to the ACGME.  Site visits will occur every 10 years.  Programs that demonstrate high quality outcomes should have more opportunity to innovate, as some of the data collection requirements will be relaxed for those programs.   

So, is this new system achieving its goals?

At this point, it is hard to know.  Milestones assessment has become a hot topic in Education research.  Milestones have received praise for being outcome-based, although Program Directors have not seen the decrease in administrative burden that was promised.   This is just personal opinion, but I suspect that we will learn that the NAS is effective at bringing poorer-performing programs up to where they need to be, but otherwise does not change much for the higher-performing programs. 

Why does accreditation matter to me?

Without accreditation, your residency training doesn’t mean much…similar to if you were to attend a medical school that was not accredited by the LCME.  A residency program needs the ACGME/RRC stamp of approval to have any sort of legitimacy.

Is this information incorrect or out of Date? Questions/Comments/or Concerns?  

Please Let Us Know!

Authorship

• Robbie Paulsen, MD - SLOE and CORD
• Jeffery Hill, MD MEd - Grand Rounds & III
• Aalap Shah, MD - SAEM, ACEP, AAEM
• Dan Axelson, MD  - ACGME, RRC
• Chris Richardson, MD - LCME
• Riley Grosso, MD  - CLER
• Erin McDonough - NAS

Page was created by Jeffery Hill, MD MEd on 8/25/17 and Last Updated on 8/25/17