Survey of Neurocritical Care Fellowship Directors Reveals
Preference for Transition to ACGME Accreditation
By Venkatakrishna Rajajee; Rajat Dhar; Anna Finley Caulfield; Matthew B Maas; Michael L James; Avinash Bhargava Kumar; Stephen A. Figueroa;
David McDonagh; and Agnieszka Ardelt on behalf of the Program Accreditation, Physician Certification and Fellowship Training (PACT) Committee
Matthew B Maas
Anna Finley
Caulfield
Michael L James
Training in neurocritical care (NCC) is currently ineligible
for accreditation by the Accreditation Council for Graduate
Medical Education (ACGME), and NCC practitioners do not
have a pathway to certification through any of the members
of the American Board of Medical Specialties (ABMS). This
is in contrast to the pathways to ACGME-accredited general
critical care training, as well as ABMS certification in critical
care, available to graduates of internal medicine, surgery,
anesthesiology, pediatrics and, most recently, emergency
medicine residency programs. A major milestone in NCC
training was the creation of pathways to accreditation and
certification through the United Council for Neurologic
Subspecialties (UCNS). An important goal of UCNS,
incorporated in 2003, was to establish these pathways for smaller
neurological subspecialties that had not reached “critical mass”
for recognition by the ACGME and ABMS.(1) The first batch of 91
NCC practitioners received UCNS certification in 2007,(2) while
the first nine NCC fellowship programs were accredited in 2008.
(3) As of 2017, however, the specialty had grown to 1,240 UCNScertified
neurointensivists,(4) and 66 UCNS-accredited fellowship
programs,(5) with representation from a wide spectrum of
background specialties. Of note, a distinct training pathway
available exclusively to neurosurgeons now exists through
the Committee on Advanced Subspecialty Training (CAST) of
the Society of Neurological Surgeons, with 16 NCC training
programs accredited by CAST as of 2017.(6)
Recognizing the remarkable growth in the field, in April 2017,
the Neurocritical Care Society’s (NCS) Board of Directors
included in its strategic plan a goal to “develop an approach to
certification that will satisfy ABMS for individuals and ACGME
accreditation of individuals’ requirements.” A transition to
ACGME-ABMS will have a major impact on the field, first and
foremost on training programs. Several questions exist about
the potential benefits versus the pitfalls of this transition. It is
in this context that the recently published 2016 survey of NCC
fellowship directors(7) is particularly significant. The survey was
one of the first tasks of the Program Accreditation, Physician
Certification, and Fellowship Training (PACT) Committee of
NCS, convened in 2015. The survey was sent out to fellowship
directors in June 2016 and was comprehensive, covering several
aspects of NCC training and practice. The focus was, however,
on program directors’ perspectives on the issues surrounding
a transition to ACGME-ABMS. Thirty-three program directors
responded to the survey. Several questions addressed the
administrative burdens of ACGME accreditation. While UCNS
requires semi-annual evaluations of fellows and written
evaluation of the program by fellows, ACGME requirements
are considerably more stringent. Several of these additional
requirements are, however, already enforced by individual
institutions, through oversight of non-ACGME fellowships by the
institutions’ offices of Graduate Medical Education. In the survey,
the majority of programs were already required to comply with
most of these requirements (See Figure 1). Nonetheless, having
to fulfill all these requirements will inevitably increase the
administrative burden on the remaining programs.
ACGME accreditation may also be associated with administrative
benefits in the form of required support from sponsoring
institutions. While some ACGME-accredited specialties such
as neurosurgery do not mandate such support, others, such as
neurology, do. Institutions with ACGME-accredited vascular
neurology fellowship programs are required to provide at
least 10 percent salary support to the fellowship director and
financial support for an administrative coordinator. Among
NCC programs surveyed in 2016, however, most programs did
not receive any institutional support (See Figure 2). Fellows
in ACGME-accredited training programs are not allowed to
bill independently for either evaluation/management (E/M)
services or procedures, which may lead to a loss of revenue for
some programs. In the survey, however, 76 percent of directors
reported that their fellows were already not permitted to
independently bill for E/M services or procedures.
While the absence of ACGME accreditation, might, in theory,
turn residents away from NCC as a specialty, program directors
did not think this was happening; only 22 percent believed
that their ability to recruit excellent candidates was negatively
affected by the absence of ACGME accreditation and 34 percent
believed that job prospects of fellows were adversely affected.
Larger factors related to the evolution of NCC as a specialty
may also shape program directors’ opinions. As efforts are again
Venkatakrishna
Rajajee
Avinash Bhargava
Kumar
Rajat Dhar
Stephen A. Figueroa
Agnieszka Ardelt
David McDonagh
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