The health care system in the United States is evolving quickly, with ongoing impacts on the field of Physical Medicine and Rehabilitation (PM&R). In order for the specialty to remain relevant and to thrive in the future, residency programs must also evolve to produce PM&R physicians who are able to provide competent care within new systems and environments. An important opportunity to ensure that PM&R training provided in graduate medical education (GME) is both relevant and forward-thinking to meet the needs of all relevant stakeholders, is through the revision process of residency program requirements at the Accreditation Council for Graduate Medical Education (ACGME). This opportunity was targeted for strategic planning by the leadership of the three major physiatry organizations: the American Academy of PM&R (AAPM&R), Association of Academic Physiatrists (AAP), and the American Board of PM&R (ABPM&R), with recognition that collaboration with shared resources would achieve the broadest input into identifying potential residency training requirement revisions that will best prepare physiatrists for future practice. The timeline and scope of this collaboration, and the details of the final recommendations provided to ACGME, are described in this article. Additional details are included for select recommendations that required deeper discussion and debate. The collaboration between the sponsoring organizations for this project extended over 8 years (Figure 1). Following strategic discussions in 2015, the leadership of the three participating PM&R organizations convened a GME summit in Chicago in July 2017, which was attended by more than 50 physician organizational representatives. The attendees discussed the existing PM&R GME curriculum scope and content, as well as funding challenges for PM&R residencies. The summit provided the impetus for the three PM&R organizations to form the Tri-Organizational GME Commission (TGC), with broad membership representation from both academic and private practice settings. Given the large scope of the project, the TGC contracted with an executive management consulting firm to assist with project management and independent data collection. The primary goal of the TGC project was to provide broad input to the ACGME Review Committee for PM&R Residency Committee (RCPMR) in advance of the ACGME's planned revisions to PM&R residency training requirements scheduled for 2024. All residency training programs in PM&R are accredited through the ACGME, which provides detailed program requirements for each core residency and many fellowship programs.1 The Core Competencies (Professionalism, Patient Care and Procedural Skills, Medical Knowledge, Practice-based Learning and Improvement, and Interpersonal and Communication Skills) provide a conceptual framework describing the required domains for a trusted physician to enter autonomous practice.1 Compliance with these program standards is assessed in numerous ways including annual data collection and evaluation, surveys, and site visits. Requirements are set, and compliance with those requirements is assessed, by specialty-specific review committees comprising volunteer physician experts in the field, including residents/fellows as well as public representatives. The review committees regularly review the accreditation requirements to ensure that they are based on current and best practices in the field. The existing ACGME program requirements for all medical specialties must be reviewed by each Review Committee (RC) every 10 years to assess the need for revision. Prior to drafting major revisions to existing requirements, all ACGME committees must solicit input on the requirements currently in effect from the community of interest and the public.2 In 2017, the ACGME Board of Directors initiated a new process for the program requirement revisions for all specialties, beginning with the RC for Internal Medicine (IM).3, 4 This new process utilized scenario-based strategic planning and thus required the RC and the IM field to think rigorously and creatively about envisioning the future of the specialty (recognizing that the future is marked with significant uncertainty) prior to making its revisions.3 Following a number of scenario planning workshops envisioning IM in the year 2035, the IM RC applied the insights gained during the workshops to reassess existing program requirements and begin the major revision process. Subsequent to IM, Family Medicine (FM) and Pediatrics have both pursued program revision changes using a similar modus operandi for guiding their revisions.5 The RCPMR is in the next group of medical specialties using this new process for revisions to residency training requirements, which the ACGME began in December 2023. The TGC's initial work included an analysis of recent data on physiatry practice trends as well as individual interviews with a number of leaders in the field of PM&R, including representation from both academic and non-academic PM&R, through a contracted consultant.6, 7 The review of current practice trends included an assessmnet of the types of conditions treated and procedures performed by physiatrists as well as the factors impacting current physiatric practice, including competition, population health, payment models/coverage limitations and the expanded health care settings of PM&R practices and the different roles that physiatrists provide within health care systems. Information from the AAPM&R BOLD initiative, AAP workforce study, resident census surveys, and each TGC sponsor organization's member practice profiles, were reviewed throughout the process.6-10 Based on this collective data, the TGC developed a PM&R practice framework, combining current and projected future practice states. Residency training recommendations derived from the data analysis were presented at the AAP's Residency and Fellowship Program Directors (RFPD) Workshop in 2020. To obtain feedback on these initial recommendations, a focus group consisting of practicing physiatrists from both academic and private practice settings were invited to participate in an interactive webinar led by the consulting group in May 2021. These participants were selected by the TGC steering committee to represent diverse perspectives and included consideration of practice settings (academic and nonacademic; inpatient, outpatient, and proceduralist care); geographic region; diversity, equity, and inclusion (DEI) representation; and years in practice (including the span from early career physiatrists to those still in practice and at the end of their career). There was consensus within the focus group that the recommendations for training revisions should include general themes and not be proscriptive, and allow for flexibility, preserving the inherent and advantageous variety of strengths in the existing training programs. The focus group had several recommendations, the most consistent being that all residents be trained as PM&R generalists in "the core" of PM&R practice, without an option for subspecialization early in the training program. The focus group also emphasized the need for residency training requirements to ensure inclusion of the multiple settings in which physiatrists practice, particularly the addition of skilled nursing facilities, a growing practice setting. The focus group participants felt that the majority of PM&R core principles are applied in many different practice settings, citing as an example musculoskeletal medicine occurring in the management of both inpatients and outpatients. The focus group participants endorsed the skills and competencies addressed in the existing ACGME Milestones for PM&R Residencies as well as in the ABPM&R initial certification examination outline as broad and accurate, without the need for any additional lists of expected skills to be attained during residency training.11, 12 A subgroup of the TGC was created at the end of 2021 and tasked with incorporating the input and recommendations rendered from the focus groups and TGC steering committee into a format that would be translatable to the ACGME RCPMR process for suggested revisions for PM&R program requirements. A rationale for each proposed requirement revision was included to provide background and logic behind the revisions, both for the TGC members and for the RCPMR. The TGC approved the subgroup's recommendations and shared the suggested revisions to the broader community of PM&R program directors, fellowship directors, and department/division chiefs through scheduled webinars in April 2022. Following the webinars, the attendees provided feedback on the recommendations through a survey to assess the degree of agreement (Likert scale of strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree) with potential requirement revision topics that the TGC was considering in its input that would be provided to the ACGME RCPMR (see Appendix B). The survey topics encompassed overall duration of PM&R training, integration of the intern year into the PM&R residency program instead of preliminary or transitional years, the use of interval competency assessments to allow for curricular flexibility, the use of case logs for procedural assessments, and the existing number of required electrodiagnostic procedures. A total of 110 attendees screened the webinar and 70 of these participants provided input, partially or completely, through a follow-up survey. Survey results were reviewed by the TGC and subsequently shared with the PM&R GME community at the 2022 AAP RFPD Workshop in New Orleans. The survey questions with the greatest response variability were related to the proposed change in the number of required electrodiagnostic experiences, with 38% of respondents disagreeing or strongly disagreeing that the completion of 150 performed electrodiagnostic studies should remain unchanged as a program requirement. This led to additional efforts by the TGC subgroup to understand the history behind this pertinent program requirement. Review of historical ACGME program requirements revealed that the requirement of 200 electrodiagnostic experiences has been maintained in written residency program requirements since at least 1996.13 Current program requirements (Program Requirement (IV.B.1.b). (2). (a)) mandate a minimum of 200 electrodiagnostic evaluations, of which 150 are separate patient encounters in which the trainee demonstrates competence in the performance, documentation, and interpretation of the study.1 In 2015, the ACGME published a memorandum entitled, "Minimum Number of Physical Medicine and Rehabilitation Procedures" that established the minimum expectations for resident performance of selected PM&R procedures during an entire residency.14 Included within this list of procedures was an expectation that each resident maintain a case log of both observed and performed electromyography/nerve conduction studies (EMG/NCS). This has been referred to as the "200/150 requirement." These minimum expectations for EMG/NCS also replicate the requirement already in place, separately, in the program requirements ((Program Requirement IV.B.1.b). (2). (a)). The memorandum indicated that although these requirements provided a minimum exposure quantification, this exposure did not signify achievement of an individual resident's competence in a particular procedure. Residency program directors were provided the latitude to determine the entire educational experience for each resident, considering each resident's particular abilities. Following the May 2022 AAP RFPD meeting, the TGC had multiple meetings with the AAP RFPD Committee, and the American Association of Electrodiagnostic & Neuromuscular Medicine (AANEM) leadership. An additional EMG Focus Task Force Group was convened external to the TGC to further dissect and reconsider recommendations on future training requirements specific to electrodiagnosis. Ultimately, consensus was not achieved regarding recommendations to revise the number of required electrodiagnostic studies. The TGC did, however, achieve consensus on a recommendation to remove the existing duplicative ACGME program requirements specific for electrodiagnostic studies, and to recommend ongoing utilization of the case log entry of EMG/NCS within the ACGME Case Log Entry System, thus maintaining consistency between all existing PM&R procedural training expectations. The TGC recognized the historical and longitudinal value of electrodiagnostic training to teach anatomy and neurophysiology to physiatrists. Although acknowledging the benefits of electromyography training in PM&R, the TGC received significant feedback that the time devoted exclusively to electromyography training—nearly 6 months at many programs—was excessive given the advent of numerous other procedural tools now utilized in PM&R practice, such as ultrasound and spasticity management procedures. Concerns were raised about the existing EMG training requirement hindering opportunities for other training experiences, both procedural and nonprocedural. The TGC recommended that the RCPMR, and its designated program revision committee, consider this concern in reviewing this singular procedural program requirement. A recommendation was made to the RCPMR to continue case log requirements for electrodiagnostic testing along with all other neuromuscular procedures and to consider the impacts, both positive and negative, on drafting a change to the existing case log numerical requirement. An overarching theme of the TGC's suggested revisions provided to the ACGME RCPMR was to evolve PM&R training toward a competency-based medical education approach, rather than time-determined rotation lengths, in order to determine adequate exposure to the core areas of physiatric training and to provide opportunities for residents to gain additional experience in areas of interest. This theme was consistent with those specialties that have completed their program requirement revisions using scenario planning, including internal medicine and family medicine.15 The TGC received consistent input that there should be no change to the overall duration of PM&R residency training and that the core areas of PM&R training should be maintained in PM&R residency training. The TGC's final recommendations were presented to the leadership committees of the three sponsoring organizations in an interactive webinar in January 2023. The recommendations were approved by all three TGC organizational sponsors. With this final review and approval, the report from the TGC was submitted to the ACGME RCPMR in July 2023 (see Table 1 and Appendix A for details). The ACGME's process of review and revision of PM&R residency standards began with a kick-off meeting in December 2023. At that meeting, TGC representatives presented the commission's process, final recommendations, and rationales for the changes proposed, and also participated in initial critical discussions of required competencies and training priorities. It is the hope of the TGC that the very broad input from the field of PM&R and the many thoughtful discussions reflected in the TGC final report will facilitate and streamline the revision process and will provide welcome guidance to the ACGME RCPMR as it undertakes this vital project. The authors would like to extend gratitude to the steering committee members of the Tri-Organizational Graduate Medical Education Committee including: Kevin Carneiro, D.O., Sara Cuccurullo, M.D., Danielle Perret Karimi, M.D., Tiffany Knowlton, J.D., M.B.A., James McDeavitt, M.D., Mary McMahon, M.D., and Thomas Stautzenbach, M.A., M.B.A. We would also like to share our sincere thanks to members and diplomats of each of the three organizations who provided exceptional input for consideration into the recommendations that have been provided to the PM&R Program Revision Committee at the Accreditation Council for Graduate Medical Education. This article has been simultaneously co–published with American Journal of PM&R. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. Dr. Kinney serves as Executive Director of the American Board of Physical Medicine & Rehabilitation (ABPMR). Dr. Pruitt serves on the ABPMR Board of Directors. Dr Burris reports payment from Abbie (speaker's bureau). Appendix S1. Supporting Information. Appendix S2. Supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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