Marking the path forward with milestones.

Race and Ethnicity of Pediatric Trainees and the Board-Certified Pediatric Workforce

Validity Evidence for the General Pediatrics Board Certification Examinations: A Practice Analysis

Competency-based medical education (CBME) is an outcomes-based approach that has taken root in residency training nationally and internationally. CBME explicitly places the patient, family, and community at the center of training with the primary goals of concomitantly improving both educational and clinical outcomes. Family medicine, as the foundational primary care discipline, has always embraced the importance of linking training with health system needs and performance since its inception. While CBME is no longer a new concept, full implementation of this outcomes-based approach has been daunting and challenging. Gaps in the effectiveness, safety, equity, efficiency, timeliness, and patient/family centeredness of health and health care in the United States continue to be persistent and pernicious. These gaps summon family medicine and the entire graduate medical education system to take stock of its current state and to examine how more fully embracing an outcomes-based educational approach can help to close these gaps. This article provides a brief history of the CBME movement, and more importantly, its key underlying educational principles and science. I will explore the key inflection points of progress, including identifying core CBME components, introduction of competency Milestones, experimental pilots of time variable training, advancements in mastery-based learning, and advances in work-based assessment, within the context of family medicine. I will conclude with suggestions for accelerating the adoption and implementation of CBME within family medicine residency training.

The Next Phase of Pediatric Residency Education: The Partnership of the Milestones Project

Internal Medicine 2035: Preparing the Future Generation of Internists.

Editorial introductions.

Every medical school aims to provide better education, and it sometimes requires changing the current education system. However, an attempt for a change may not always be successful. In many cases, it is so not because an intended change was not properly directed but because conflicts in the process of adopting the change were not properly handled. This paper suggests seven points for how to successfully bring a change in medical education. First, the medical education should not simply focus on the pass rate of the national medical examination but also on the cultivation of creative leaders. Second, the faculty of medical school should be creative, self-motivated, and passionate. Third, people in charge of an intended change should have a good understanding of complicated dynamics between the dean’s office, medical education experts, professors, and students. Fourth, people who are leading the change should also grasp the possibility that a well-intended change might not be well-received by professors, students, and dean due to their tendency to be complacent with the current system. Fifth, a successful introduction of a change requires good teamwork of a thinker, an actor, and a coordinator. Sixth, a change takes time as it takes place through a step-by-step process. Seventh, an attempt for a change accompanies a negotiation with professors with different thoughts and views regarding education, and people who want a change need to be flexible in that negotiation. In addition to these seven points, people who are responsible for a change should be consistent and consider the renown of the school.

Competency-based medical education (CBME) curricula are becoming increasingly common in graduate medical education. Put simply, CBME is focused on educational outcomes, is independent of methods and time, and is composed of achievable competencies.1 In spite of widespread uptake, there remains much to learn about implementing CBME at the program level. Leveraging the collective experience of program leaders at Queen’s University, where CBME simultaneously launched across 29 specialty programs in 2017, this paper leverages change management theory to provide a short summary of how program leaders can navigate the successful preparation, launch, and initial implementation of CBME within their residency programs.

Competency-based medical education (CBME) places a premium on both educational and clinical outcomes. The Milestones component of the Next Accreditation System represents a fundamental change in medical education in the United States and is part of the drive to realize the full promise of CBME. The Milestones framework provides a descriptive blueprint in each specialty to guide curriculum development and assessment practices. From the beginning of the Outcomes project in 1999, the Accreditation Council for Graduate Medical Education and the larger medical education community recognized the importance of improving their approach to assessment. Work-based assessments, which rely heavily on the observations and judgments of clinical faculty, are central to a competency-based approach. The direct observation of learners and the provision of robust feedback have always been recognized as critical components of medical education, but CBME systems further elevate their importance. Without effective and frequent direct observation, coaching, and feedback, the full potential of CBME and the Milestones cannot be achieved. Furthermore, simply using the Milestones as end-of-rotation evaluations to "check the box" to meet requirements undermines the intent of an outcomes-based accreditation system. In this Commentary, the author explores these challenges, addressing the concerns raised by Williams and colleagues in their Commentary. Meeting the assessment challenges of the Milestones will require a renewed commitment from institutions to meet the profession's "special obligations" to patients and learners. All stakeholders in graduate medical education must commit to a professional system of self-regulation to prepare highly competent physicians to fulfill this social contract.

Professional identity formation, with its focus on the development of professional values, actions, and aspirations, is the ideal goal of medical education. Medicine is a community of practice, and medical education is a socialization process by which novice trainees become full community members. The authors believe coaching provides an ideal means for promoting this socialization process to develop a learner's identity as they engage in the community. Coaching involves an orientation toward growth and development, valuing reflection and nurturing continuous reflection, and embracing failure as an opportunity for learning. However, there are challenges to implementing coaching in medical education. Competency-based medical education has provided clear outcomes (competencies) for medical education and programs of assessment around these competencies. Yet, there is a tension in medical training between professional identity formation (the process of socialization into the profession) and the formal assessment process. The ideal of multiple low-stakes assessments and written evaluations, intended as formative assessments, are perceived by residents as high-stakes evaluations with significant consequences for their future. The authors present a resident story that highlights this tension. They outline Goffman's theory of impression management, postulating that medicine's assessment system encourages residents to stage a performance for evaluators that displays their competence and conceals their perceived weaknesses. This performance hinders coaching and the formation of an appropriate professional identity. Coaching, the authors believe, provides a model that aligns assessment and professional identity formation. Given the challenges to implementing coaching in medical education, the authors propose several questions to contemplate when integrating coaching into medical education to facilitate the goal of professional identity formation.

Current Opinion in Pediatrics was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of pediatrics are divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editor and Section Editors for this issue. EDITOR Philip A. PizzoPhilip A. PizzoPhilip A. Pizzo, MD, is the David and Susan Heckerman Professor and Founding Director of the Stanford Distinguished Careers Institute, USA. Dr Pizzo served as Dean of the Stanford School of Medicine from April 2001 to December 2012, where he was also the Carl and Elizabeth Naumann Professor of Pediatrics and of Microbiology and Immunology. Dr Pizzo has devoted much of his distinguished medical career to the diagnosis, management, prevention and treatment of childhood cancers and the infectious complications that occur in children whose immune systems are compromised by cancer and AIDS. He has also been a leader in academic medicine, championing programs and policies to improve the future of science, education and healthcare in the US and beyond. Dr Pizzo received his MD degree with Honors and Distinction in Research from the University of Rochester, USA in 1970, and completed an internship and residency at Children's Hospital Medical Center in Boston, USA, a teaching fellowship at Harvard Medical School, USA, and a clinical and research fellowship in pediatric oncology at the National Cancer Institute. Pizzo served as Head of the Institute's Infectious Disease Section, Chief of the NCI's Pediatric Department, and Acting Scientific Director for NCI's Division of Clinical Sciences between 1973 and 1996. Before joining Stanford in 2001, he was the Physician-in-Chief of Children's Hospital in Boston and Chair of the Department of Pediatrics at Harvard Medical School, where he was also the Thomas Morgan Rotch Professor of Pediatrics. Dr Pizzo is the author of more than 615 scientific articles and 16 books and monographs, including Principles and Practice of Pediatric Oncology, the Seventh Edition of which was published in 2015. He co-led a multidisciplinary committee for the Institute of Medicine (IOM) that resulted in the 2011 report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research; he also co-chaired the IOM report Dying in America: Improving Quality and Honoring Individual Preferences at the End of Life, which was published in 2015. Dr Pizzo has received numerous awards and honors, among them the Public Health Service Outstanding Service Medal in 1995, the Barbara Bohen Pfiefer Award for Scientific Excellence in 1991, the Elizabeth Kubler-Ross Award in 2008, the Ronald McDonald Charities Award of Excellence in 2009, and the John and Emma Bonica Public Service Award in 2013. He is the 2012 recipient of the John Howland Award, the highest honor for lifetime achievement bestowed by the American Pediatric Society. He has been elected to a number of prestigious organizations and societies, including the Association of American Physicians, the American Society of Clinical Investigation, the American Pediatric Society and the Institute of Medicine of the National Academy of Sciences, where he was also elected to the Governing Council. The IOM became the National Academy of Medicine in 2015. Dr Pizzo has served as Chair of the Association of Academic Health Centers, and Chair of the Council of Deans of the Association of American Medical Colleges, and was elected to the Board of Directors of the American Society for Clinical Oncology and the Infectious Diseases Society of America. He was President of the International Immunocompromised Host Society (1998–2011). He served on the Governing Board for the California Institute of Regenerative Medicine from 2004–2012. In 2009 he was elected to the Board of Trustees of the University of Rochester and the Board of Overseers of Koc University in Istanbul, Turkey. He is also a member of the Board of Directors of MRI Interventions and the Academic Advisory Council for Merritt Hawkins. In 2014 he was elected to the Board of Directors of the Ludwig Institute for Cancer Research and in 2015 he was elected to the Board of Directors of Global Blood Therapeutics. SECTION EDITORS Susan M. BlaneySusan M. BlaneySusan M. Blaney, MD, is a Professor and Executive Vice Chair for the Department of Pediatrics at Baylor College of Medicine, USA and the Director of Texas Children's Cancer Center at Texas Children's Hospital, USA. She is a board-certified pediatric oncologist whose career over the past 25 years has focused on the development of new agents and therapeutic strategies for children with recurrent or refractory cancer, particularly for those with malignancies of the central nervous system. She has extensive experience in clinical translational research and currently serves as the Vice Chair for the Children's Oncology Group (COG), an NCI-funded cooperative effort of 200 leading children's hospitals across North America. Dr Blaney has played a leadership role in the development of numerous early phase clinical trials of novel agents for the treatment of childhood cancer over the course of her career. Dr Blaney has also served as a mentor to many pediatric medical students, residents, fellows and faculty who are current or developing leaders in the field of pediatric oncology. Her influence in the field also extends to numerous advisory roles that she has held including an service on the National Cancer Institute's Clinical Trial Advisory Committee, as a member of the Investigational Drug Steering Committee for the National Cancer Institute, as a regular consultant for the FDA's Pediatric Oncology Drug Advisory Committee, as well as for other leading cancer organizations such as the American Association for Cancer Research and the American Society of Clinical Oncology. She also directs or has served on the scientific advisory boards for many not-for-profit foundations for childhood cancer research. Dr Blaney has published more than 200 articles in peer-reviewed journals, has authored numerous book chapters, and is an editor for Rudolph's Pediatrics as well as an Associate editor for Pizzo and Poplack's Principles and Practice of Pediatric Oncology, the leading textbook in the field of pediatric oncology. Daniel W. GreenDaniel W. GreenDr Daniel W. Green has been practicing at the Hospital for Special Surgery, USA since 1998 and is currently the Director of the Pediatric Sports Program for the Division of Pediatric Orthopedic Surgery. While he thoroughly enjoys caring for patients from birth into early adulthood, he has a special interest in pediatric sports injuries and pediatric knee injuries, in addition to pediatric orthopedic trauma. He provides emergency treatment for pediatric fractures and other orthopedic emergencies at New York Presbyterian Hospital-Manhattan, USA and the Hospital for Special Surgery. His focus is to provide the finest, most advanced orthopedic care available and is devoted to advancing treatments in order to improve patient outcomes and the overall patient experience. His research focuses on pediatric knee surgery, cartilage repair and restoration, pediatric ACL surgery, pediatric growth plate surgery, pediatric fracture care, and osteogenesis imperfecta. He has extensively studied the surgical options for patellar dislocations, evaluating both conservative and surgical approaches to stabilizing the patella. He has also investigated surgical techniques for ACL reconstruction in the skeletally immature. Dr Green is a clinical professor of orthopedic surgery at the Weill Cornell Medical College, USA. Yvonne J. BrysonYvonne J. BrysonDr Yvonne J. Bryson is a Distinguished Professor and recent past Chief of Global Pediatrics Infectious Diseases at David Geffen School of Medicine at UCLA, Mattel Children's, USA. She is a world-renowned leader, researcher, virologist and clinician in the field of HIV pathogenesis, prevention, and treatment of maternal-fetal and pediatric HIV-1, and is an active member of the HIV CURE Scientific Committee of International Maternal Pediatric and Adolescent AIDS Clinical trials network (IMPAACT) and the Adolescent trials network for identification and treatment of HIV acute infection. She is past Chair of the NIH Network IMPAACT PMTCT Committee (Prevention of Mother-to-Child Transmission of HIV) as well as a previous past chair. She has served a national and international leadership role for the past 25 years in studies of prevention and treatment of pediatric HIV. She has served on the HIV Therapeutics Trans NIH panel to set the NIH agenda for the past eleven years. Dr Bryson was influential in the development of CDC and Public Health guidelines for the diagnosis and treatment of HIV-infected pregnant women and has been involved in the planning and execution of national cooperative studies of maternal-fetal HIV transmission. She has made significant contributions to the development of the original studies of the use of Zidovudine and Nevirapine for the prevention of perinatal HIV. She published studies of maternal risk factors for vertical transmission of HIV including viral load and autologous neutralizing antibody, as well as advances in the early diagnosis of HIV in newborns. Her research at UCLA has been funded by NIH for over twenty-five years. She has over 190 original peer-reviewed publications and is a sought-after lecturer and reviewer. She was founding advisor and one of the original health board advisors of the Elizabeth Glaser Pediatric AIDS Foundation, with co-founders Elizabeth Glazer, Susie Zeegan and Susan Delorentis, and colleagues Dr Richard Stiehm and Phil Pizzo. She participated and helped plan the EGPAF thinktanks, the Ariel Project, the Elizabeth Glazer Scientist Award, and fundraising strategies for the foundation and the role of NIH in promoting new investigators in the field. She also was involved in political activism in Washington DC and California with Elizabeth and cofounders to focus attention on children. Dr Bryson has served on numerous NIH study section reviews and panels. She had significant experience in global health issues related to reduction of maternal infant mortality and morbidity and meeting the millennium goals. Dr Bryson has had significant leadership and field experience setting up NIH funded clinical trials, laboratories and infrastructure in Brazil over the past 13 years. She has trained a large number of students and post-doctoral MD, PhD scholars and junior faculty who are now national and international leaders as academic faculty or public health professionals in the US and around the world. Dr Bryson is a strong advocate for mothers and children for the prevention and treatment of infectious disease and is now committed to the CURE for HIV. She still has active NIH RO1 grants for studies of HIV remission and cure in infants and children, collaboration on an infant maque monkey model, and most recently, studies in adolescents in Los Angeles and New Orleans. She is an expert in perinatal infections, pediatric infectious disease, antivirals herpes infections, and other viral, bacterial, and opportunistic infections, and serves as a pediatric infectious disease consultant. Henry H. BernsteinHenry H. BernsteinDr Bernstein is a Professor of Pediatrics at Hofstra Northwell School of Medicine in New York, USA. He taps into his extensive 32-year experience as a general pediatrician in private practice and in academia at urban, suburban, and rural children's hospitals to promote the health and wellbeing of children, their families, and their communities. His private, community-based primary care (generalist) experiences in combination with academic experiences have provided him with a value-added, translational science perspective, unique from many others in academia. This tacit knowledge enables him to fulfill a lifelong passion of communicating, educating, and translating science into clinical settings, educational venues, policy-making, and media interactions to advance the health of children. Research is consistently woven into the fabric of Dr Bernstein's clinical practice, which has served as a “laboratory” for his active studies. His research and quality improvement initiatives focus on issues important to Academic General Pediatrics and community-based practice, including immunizations, postpartum newborn discharge, childhood obesity, breastfeeding, health promotion, preventive health screening in primary care, technology, and medical education. His commitment, innovative spirit, and enthusiasm also encompass many facets of medical education along the continuum, from training and mentoring future physicians to fostering lifelong learning, to supporting the continuous professional development of practicing pediatricians. Hank is an ex-officio member of the American Academy of Pediatrics’ Committee on Infectious Diseases (Red Book Committee), Associate Editor of Red Book Online, and AAP liaison to the CDC Advisory Committee on Immunization Practices’ Influenza Workgroup, spearheading both seasonal and pandemic influenza preparedness and policy for children. In addition, he is Editor-in-Chief Emeritus of PediaLink, the AAP's online home for lifelong learning and chair of the interdisciplinary Bright Futures Health Promotion Workgroup, which has created a distinctive health promotion curriculum, videos, and a companion educational website (www.pediatricsinpractice.org). He regularly shares his knowledge and expertise by educating the public, writing for health information websites, and participating in media interviews on a variety of pediatric health care issues including immunization, diagnosis and treatment of common childhood infectious diseases and illnesses, and practical information for parents, teachers and caregivers. In the spirit of lifelong learning, Hank earned a masters in healthcare management at Harvard School of Public Health, USA, in 2013. He actively maintains his certification by the American Board of Pediatrics. He completed his residency training in pediatrics at St Christopher's Hospital for Children in Philadelphia, USA, after earning his medical degree from the University of Medicine and Dentistry of New Jersey - School of Osteopathic Medicine, USA. Hank and his wife, Sophie, have been married for 36 years and are extremely proud of their 31-year-old daughter, Lauren, and 26-year-old son, David.

Editorial introductions

A healthy lifestyle is fundamental for the prevention and treatment of cardiovascular disease and other noncommunicable diseases (NCDs). Investment in primary prevention, including modification of health risk behaviors, could result in a 4-fold improvement in health outcomes compared with secondary prevention based on pharmacological treatment. The American Heart Association (AHA) emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction. In addition to defining “cardiovascular health” based on criteria for blood pressure and biochemical markers (lipids and glycemia), the AHA Strategic Planning Committee further identified lifestyle characteristics of central importance: nutrition, physical activity, smoking, and maintenance of a healthy body weight.1 The World Health Organization estimated that ≈80% of NCDs could be prevented if 4 key lifestyle practices were followed: a healthy diet, being physically active, avoidance of tobacco, and alcohol intake in moderation.2 To support healthy lifestyle initiatives, major changes are necessary at the societal level to improve population health. Numerous strategies might help to create a culture that promotes and facilitates healthy behaviors, including creating laws and regulations, mounting large-scale public awareness and education campaigns, implementing local community programs, and providing individual counseling.3 Physicians are uniquely positioned to encourage individuals to adopt healthy lifestyle behaviors: Approximately 80% of Americans visit their primary care physician at least once a year. Physicians directly communicate with their patients during clinical encounters across numerous settings, and research indicates that patients highly value recommendations provided by their physicians.4,5 However, data further indicate that lifestyle counseling does not routinely occur in physicians’ offices, thereby representing a lost opportunity. Physicians report that they perform lifestyle counseling during ≈34% of clinic visits.4 Patients, in turn, report an even lower frequency of physician lifestyle counseling. For example, obese patients reported receiving physical activity and …

The aim of this study is to determine whether the 65 competencies, defined in “the role of Korean doctor, 2014”, are suitable for basic medical education phase in Korea. It seeks to analyze the gap among the educational reality and expectation, assessment situation of the competencies above. We also try to define issues of the development, application and assessment phases of competency-based medical education (CBME) at individual medical schools. We designed survey tools based on the Miller’s assessment pyramid (knowledge, explanation, demonstration, and performance) for each of the 65 competencies. The survey distributed to 41 medical schools in April 2015 and 38 replies were received (92.7%). Competencies that matched both the educational reality and expectation were numbers 1 (patient care), 33 (social accountability), and 49 (professionalism). However, all the other competencies ranked lower in current status than that of desirable level. 54 out of 65 competencies (83.07%) remained at the knowledge and explanation level when each competence were assessed. In the development, application, and assessment phases of CBME, common issues that medical schools commonly noted were difficulty linking competencies to curriculum preparation and student assessment, the lack of faculty’s understanding, difficulty to reach consensus among faculties, and absence of teaching and learning methods and assessment tools that fits CBME. For the successful settle down of CBME, there is a need for efforts to develop the model of graduate outcomes, to share information and experience, and to operate faculty development program by the medical education communities.

Medical education must evolve to meet the changing needs of patients and communities. Innovation is a critical component of that evolution. As medical educators pursue innovative curricula, assessments, and evaluation techniques, the impact of innovations may be limited by minimal funding. The American Medical Association (AMA) Innovation Grant Program, launched in 2018, seeks to address the gap in funding and stimulate educational innovation and research in medical education. In 2018 and 2019, the Innovation Grant Program targeted innovation in content areas including health systems science, competency-based medical education, coaching, learning environment, and emerging technology. The authors reviewed the content of applications and final reports for the 27 projects completed during the first 2 years of the program. They also noted measures of success (completion of project, achievement of grant objectives, development of transferrable educational product, dissemination). In 2018, the AMA received 52 submissions and funded 13 proposals, dispersing $290,000 ($10,000 and $30,000 grants). In 2019, the AMA received 80 submissions and funded 15 proposals, dispersing $345,000. Among the 27 completed grants, 17 (63%) supported innovations related to health systems science. Fifteen (56%) were used to create educational products that could be shared, such as new assessment tools, curricula, and teaching modules. Five grant recipients (29%) published articles and 15 (56%) presented at national conferences. The grant program advanced educational innovations, particularly in health systems science. The next steps will involve examining the long-term outcomes and impact of the completed projects on medical students, patients, and the health system; the professional development of the grantees; and the adoption and dissemination of the innovations.