The Program That Stayed the Same

There is a particular kind of residency program that does not show up on any watch list.

It’s accreditation is in good standing. Its board pass rates are acceptable. It has been around long enough that nobody questions whether it belongs. On paper, it is fine.

But inside GME offices, and inside the speciality, people who know what current looks like can see something that the paperwork doesn’t capture. The program hasn’t moved. Not dramatically, not in any way that would trigger a citation or concern. It has simply stayed, more or less, where it was five years go. Ten years ago. Sometimes longer.

This is one of the quieter problems in graduate medical education. And its worth naming honestly.

Tenure Is Not the Problem

Before anything else, a distinction worth making clearly.

Long tenure in the program director role is not inherently a problem. Some of the strongest programs in the country are led by people who have been in the role for fifteen or twenty years. They have used that time to build something durable. They sit on specialty boards, participate in national curriculum development, attend conferences not just to maintain credits but to bring ideas back. They have stayed curious about what their specialty is becoming and made sure their program evolved alongside it. Their longevity is an asset because they have kept earning it.

The pattern this post is about is different. It is about the program director whose tenure has become the shape of the program itself. Where the curriculum reflects what was current when they started, not what is current now. Where the operational systems haven’t been meaningfully updated in years. Where the response to most questions about why things are done a certain way is some version of: this is how we have always done it.

Length of time in the role is not what creates stagnation. The absence of evolution does. And those two things are not the same.

What Stagnation Actually Looks Like

It rarely looks like dysfunction. That is what makes it easy to miss and easy to tolerate.

It looks like a curriculum that covers the right competencies on paper but hasn’t been updated to reflect where the specialty has moved. A didactic schedule that runs the same topics in the same sequence it has for a decade. Assessment tools that were adequate when they were designed but haven’t kept pace with how the field thinks about resident development now.

It looks like operational systems that work well enough but have never been modernized. Programs where coordinators are still managing processes manually that peer programs automated years ago. Where New Innovations or similar platforms are being used at a fraction of their capacity because no one has taken time to learn what else they can do. When onboarding looks the same as it did before anyone had heard of the tools now considered standard.

It looks like a program that recruits well enough to fill its positions but has stopped asking whether it is attracting the strongest candidates or just the ones who didn’t look too closely. Where the interview process reflects what was competitive in a different era. Where the program’s identity is its speciality has quietly faded because it hasn’t contributed to the national conversation in years.

And it looks like a faculty culture that has adapted so completely to the way things are done here that nobody notices anymore that things could be done differently. Where the absence of challenge has become indistinguishable from stability.

Who Suffers and How

The residents who match into a stagnant program often don’t fully understand what they are walking into until they are already inside it. By the time they realize the gap between their training and what their peers in other programs are experiencing, they are too far into it to easily change course.

They may complete their training, pass their boards, and enter practice without ever knowing what they missed. Or they may enter fellowship or their first attending role and discover, through comparison, that they were underprepared in ways that were never their fault. That discovery is a particular kind of injury. Not the kind that shows up in outcomes data, but the kind that shapes how a physician understands what their training was worth.

Faculty suffer differently. When a program stops evolving, the faculty who joined it because they believed in its potential eventually stop bringing new ideas. They adapt to what is rewarded, which in a stagnant program is consistency and compliance rather than innovations and growth. The most ambitious ones leave. The ones who stay often do so because they have built their professional lives around the program and leaving is too costly, not because they believe the program is serving its mission.

And the program director, in many cases, suffers too, even if that is not visible from the outside. A role that was once challenging and generative can become rote. The energy that built the program in its early years has nowhere to go. The professional identity that was once tied to growth becomes tied to preservation. That is a quiet kind of stagnation, and it is not always a choice anyone made consciously.

The Institutional Blind Spot

Here is where GME offices and hospital leadership carry real responsibility.

A program in good accreditation standing is easy to leave alone. There are always programs with more urgent problems demanding attention. A stagnant program does not generate complaints, does not trigger site visits, does not land on anyone’s desk as a crisis. It simply continues, year after year, taking up a slot in the institutional GME portfolio without anyone asking whether it is earning that slot.

That is the blind spot. Accreditation compliance is the floor, not the ceiling. A program can meet every ACGME requirement and still be falling behind what the specialty expects, what residents deserve, and what the institution should be providing.

The GME office that never asks whether a program is competitive, not just compliant, is missing half its job. And the institutional leadership that funds a training program without ever asking what it is producing relative to peer programs is making an investment without checking the return.

This is not about punishing programs for being stable. It is about asking, honestly and regularly, whether stability has shaded into stagnation. Those are different things, and the difference matters to everyone inside the program.

What a Different Path Looks Like

For program directors who recognize something of themselves in this post, and some will, the honest response is not defensiveness. It is curiosity.

What does current look like in your specialty right now? Not five years go, not when you last attended a national conference, but now. What are the programs that residents most want to match into doing that you are not? What has changed in how your specialty thinks about assessment, curriculum, resident development, in the time you have been in this role?

Those questions are not indictments. They are invitations. The program director who asks them genuinely, who brings in a fresh perspective through faculty recruitment or national collaboration or a curriculum review that involves people outside the program, is doing something that serves their residents, their faculty, and ultimately themselves.

Change in this context does not require dismantling what has been built. It requires being honest about which parts of what was built still serve the mission and which parts are being maintained out of habit rather than purpose.

That distinction, applied with honesty and some courage, is the beginning of something better.

A Question Worth Asking

If you lead a GME office or sit in institutional leadership, here is the question this post is really asking:

When did you last evaluate your programs not for accreditation compliance but for genuine competitiveness? Not whether they are meeting the minimum standard but whether they are meeting the standard of what excellent training looks like in this specialty, right now, in this moment?

If the honest answer is that you don’t know, or that it has been a while, or that you have been meaning to look more closely but the urgent things keep coming, that is worth sitting with.

The programs that stay the same while everything around them moves forward are not failing in any dramatic way. They are simply not serving their residents, their faculty, or their institutions as well as they could.

And that is enough of a reason to look honestly at what you have, and ask whether it is still what it need to be.

Closing Reflection

Longevity in this work is worth respecting. Building a program takes years and the people who have done it deserve acknowledgement for what costs.

But the respect owed to long service is not the same as immunity from honest evaluation. The programs that serve their residents best are not the ones that have been around the longest. They are the ones that have kept asking, year after year, whether what they are doing is still good enough.

That question, asked genuinely and answered honestly, is what separates a program that endures from one that merely persists.

The residents arriving this year deserve the first kind.