In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced the six domains of clinical competency to the profession, 1 and in 2009, it began a multiyear process of restructuring its accreditation system to be based on educational outcomes in these competencies. The result of this effort is the Next Accreditation System (NAS), scheduled for phased implementation beginning in July 2013. The aims of the NAS are threefold: to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME's movement toward accreditation on the basis of educational outcomes, and to reduce the burden associated with the current structure and process-based approach.Self-regulation is a fundamental professional responsibility, and the system for educating physicians answers to the public for the graduates it produces. 2 As the accreditor for graduate medical education (GME), the ACGME serves this public trust by setting and enforcing standards that govern the specialty education of the next generation of physicians. In this article, we discuss the NAS, including elements and attributes of interest to stakeholders (program directors, leaders of sponsoring institutions, ACGME's partner organizations, residents, and the public). The ACGME's public stakeholders have heightened expectations of physicians. No longer accepting them as independent actors, they expect physicians to function as leaders and participants in team-oriented care. Patients, payers, and the public demand information-technology literacy, sensitivity to cost-effectiveness, the ability to involve patients in their own care, and the use of health information technology to improve care for individuals and populations; they also expect that GME will help to develop practitioners who possess these skills along with the requisite clinical and professional attributes. 3-7 Limitations of the Current S ys temWhen the ACGME was established in 1981, the GME environment was facing two major stresses: variability in the quality of resident education 8 and the emerging formalization of subspecialty education. In response, the ACGME's approach emphasized program structure, increased the amount and quality of formal teaching, fostered a balance between service and education, promoted resident evaluation and feedback, and required financial and benefit support for trainees. These dimensions were incorporated into program requirements that became increasingly more specific during the next 30 years.The results have been largely salutary. Performance on certifying examinations has improved, residents are prepared to deal with the dramatically increasing volume and complexity of information in their specialty, and graduates and academic institutions have contributed to clinical advances and innovation that the public enjoys today. 9,10 In addition, the role of the program director has been established as an educational career path, and the formal teaching and assessment of residents and fellows have improve...
Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem.
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