The Gastroenterology Core Curriculum, Third Edition

Is Nephrology Fellowship Training on the Right Track?

COUNTERPOINT: Should Interventional Pulmonology Be Given American Board of Internal Medicine Subspecialty Status? No

The Accreditation and Certification System After Next

The common wisdom at the end of the 20th century was that the United States was training too many specialists, including cardiologists.1 By 2001, however, there was increasing evidence that the supply of cardiologists was not meeting the growing demand. That year, as president-elect of the American College of Cardiology (ACC), I appointed a task force to evaluate cardiology workforce. The task force undertook a 2-year process of literature review, hypothesis generation, research design, data acquisition, and analysis. This intense effort included a Bethesda Conference at which consensus was achieved on a report that will be published in the Journal of the American College of Cardiology . Based on various types of information and data, the ACC task force concluded that the United States is facing a shortage of cardiologists. This will reduce access to specialty care of proven benefit and will undermine our nation’s vital cardiovascular research effort. The Bethesda Conference report includes 8 working group documents that recommend several short- and intermediate-term strategies to help narrow the growing demand-supply gap for cardiologists (see Table 1). Some recommendations can be implemented at a local practice or institution level. Others will require a series of complex and coordinated actions at a national level. Hopefully, the report will catalyze actions by academic medical centers, regulatory organizations, federal policymakers, professional societies, and others that influence the output of cardiovascular specialists. View this table: TABLE 1. Working Groups of the ACC Task Force on Workforce Several things continue to drive demand for cardiologists. Elsewhere, I have argued that various scientific, social, and demographic “demand catalysts” outweigh factors that might decrease demand for cardiologists during the next decade2 (see Table 2). Although the relative influence of each demand factor will change over time, one thing is certain: the cardiovascular disease burden in the United States …

To assess the correlation of the number of months of clinical training with clinical knowledge, as measured by the United States Medical Licensing Examination (USMLE) Step 2. The total number of months of clinical training and percentile scores on USMLE Step 2 were determined for 217 Stanford. University School of Medicine graduates from 1992 through 1994. Percentile scores on each subsection of the Medical College Admission Test (MCAT) and the National Board of Medical Examiners Part 1 or USMLE Step 1 (Part 1/Step 1) for the graduates were also determined. For some analyses the graduates were separated into three groups according to the duration of clinical training. The Pearson product-moment correlation coefficient was used to quantify and define the significance of correlations. The Jorickheere-Terpstra nonparametric test was used to assess trends across the three groups. A multiple linear regression model was used to test the effects of confounding variables. The total numbers of clerkship months ranged from 12 to 23; the median was 18. A highly significant correlation was found between increasing months of clinical training and increasing scores on Step 2 (p = .002); a weaker significant correlation was found with scores on Part 1/Step 1 (p = .03). The correlation for Step 2 scores did not diminish appreciably (p = .004) when scores for Part 1/Step 1 and each MCAT subsection were introduced into the regression model. A highly significant correlation was found between the amount of clinical training and the acquisition and utilization of clinical knowledge. In the current climate of concerns about the rising costs of medical education, the impulse to solve these concerns by decreasing the amount of medical students' clinical training should be approached with caution.

In the Next Accreditation System, resident performance and progression assessed through educational Milestones will be used as 1 of a number of quality indicators to evaluate the educational effectiveness of residency programs. The Anesthesiology Milestones will be used to measure the success of individual anesthesiology residents in achieving expected goals of training, and the effectiveness of the residency program will in part be evaluated based on aggregated Milestone performance data.The members of the Anesthesiology Milestone Working Group were selected by the Residency Review Committee (RRC) for Anesthesiology, with input from the American Board of Anesthesiology (ABA), the Society for Education in Anesthesia, and program directors. The working group included 9 physician anesthesiologists, the executive director of the Anesthesiology RRC, and an Accreditation Council for Graduate Medical Education (ACGME) consultant. Four of the physician members were representatives from the Anesthesiology RRC (1 also served as the designated institutional official of a university-based medical center), 2 were former directors of the ABA, 2 were anesthesiology program directors, and 1 was an anesthesiology resident in the final year of training. An anesthesiologist who did not participate in the development of the Anesthesiology Milestones was appointed to the multidisciplinary expert panel that developed cross-specialty Milestones for interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice suggested for use by all specialties. Working group members were provided access to Milestone documents developed by several specialties that were a part of the initial stage in Milestone development. These models were used as templates to approach the task of developing anesthesiology-specific Milestones.The Anesthesiology Milestone Working Group held its first face-to-face meeting in February 2012, at which the ACGME consultant, who had experience working with prior Milestone working groups, provided an overview of the approach ACGME envisioned for the development of specialty-specific Milestones and shared lessons learned from Milestone development in the Phase 1 specialties. Based on the ACGME's recommendation that each Milestone should contain 5 levels of assessment (corresponding to the range from beginner to expert), initial discussions focused on determining if Milestone levels could be correlated with levels of residency training (clinical base year, clinical anesthesia years 1–3, and graduation). After recognizing that in their final form the levels would be independent of strictly time-based markers, the group made the decision that each Milestone level would represent expectations at the end of a point on the educational continuum. As a part of that continuum Level 1 Milestones were set as the expectations at the end of clinical base training. Level 2 Milestones were set to represent training expectations at the end of foundational (nonsubspecialty) clinical anesthesia training. Level 3 Milestones were set to represent the expectations for a resident at the midpoint of training after having been exposed to all subspecialty areas within anesthesiology. Level 4 Milestones were set to represent the expectations for a physician ready to practice anesthesiology independently without supervision. Level 5 Milestones were set to represent advanced characteristics of independently practicing physicians and were considered aspirational goals (a few of which might be achieved by a subgroup of exceptional residents during their training).After completion of the first draft of the Anesthesiology Milestones, the committee solicited feedback from members of the Association of Anesthesiology Core Program Directors (AACPD) and the Society for Education in Anesthesiology during their 2012 annual meetings. At the AACPD meeting feedback was provided formally through an audience response system that allowed program directors to respond to questions of relevance, importance, and measurability of each Milestone. Following these meetings, the working group edited the Milestones based upon the feedback received. This revised draft was then distributed to all program directors who were asked to provide constructive feedback through an electronic survey tool allowing confidential, individualized feedback from the program directors to the working group. The feedback was reviewed by the committee and used to make additional modifications to the Anesthesiology Milestones.The working group developed Milestones for each of the 6 ACGME competencies over the course of multiple face-to-face meetings and teleconferences. The patient care and medical knowledge Milestones, which are unique to each specialty, were developed first, and generic Milestones developed by a multispecialty panel were used as a starting point for the development of Milestones for the competencies of interpersonal and communications skills, problem-based learning and improvement, professionalism, and systems-based practice.The working group recognized the potential increase in workload that Milestone evaluation will place on program directors and Clinical Competency Committees (CCCs), and refined the number of Milestones to ensure appropriate assessment of competencies at each level of training, while not making the Milestones so granular that the evaluation process would be too burdensome. In the final version, the number of Milestones was reduced to 25. The working group believed this number provided an appropriate balance between comprehensiveness and practicality. The distribution of the Anesthesiology Milestones across the 6 competencies is shown in the table in this Introduction.While the working group sought input from the anesthesiology educational community to ensure that the Milestones were appropriate for assessing anesthesiology resident progression, the working group also recognized that the value of the proposed Milestones would benefit from an initial assessment using a pilot study in selected programs. A representative group of 20 anesthesiology programs has been selected to participate in the pilot study. The pilot will use the CCC in each program to assess the residents using the current Milestones. An evaluation tool has been developed for the program directors to provide the working group with feedback on each Milestone. The working group anticipates that the current version of the Anesthesiology Milestones will require modification over time as the specialty gains experience with this evaluation process. Once the final version of the Milestones is incorporated into training program evaluation, the RRC and other stakeholders will need to monitor and modify the Milestones based on experience so that they provide meaningful assessment of the residents, allowing anesthesiology training programs to foster excellence and optimize the educational experience for each trainee.The goal of the working group's effort was to produce Milestones that will provide program directors and CCC members with a progressive resident assessment tool that more readily identifies areas of strength and areas in need of improvement for each trainee. As Milestone data is accumulated in a department, the performance of an individual resident can be readily compared to peers and the course of progress of individual residents and residency levels in all 6 competencies domains can be evaluated. In addition, the program will have information about resident performance across the entire residency complement that will allow it to identify areas in which to focus educational efforts.The Next Accreditation System requires that accredited programs appoint CCCs to monitor residents' progress. The CCC is not new to anesthesiology training programs; the ABA has required submission of CCC reports for more than 25 years. The working group recognized that the Milestones represent a different and important approach to assessment of resident performance and progression. Although CCCs have been instrumental in assessing residents in anesthesiology programs, incorporation of Milestones into the assessment process will require modifications of the assessment process, faculty development to understand the Milestones and their implications and changes in the assessment, and communication with residents regarding performance.Based on the addition of Milestones in the assessment process, anesthesiology programs may have to modify the composition of the CCCs to ensure representation of all subspecialties and faculty involved in all levels of training. The ideal size of the CCC will likely vary by program based on the number of residents and faculty in the program. Regardless of the size of the CCC, faculty development will be the cornerstone in the transition to Milestones as a method for assessing clinical performance and progression through training. The working group recognized that as CCCs gain experience with incorporating Milestone assessments into their decisions, modifications of assessment strategies may be required. In addition, some Milestones may be difficult to assess in the traditional clinical environment because of the changing clinical environment and case distribution. Not all residents will be presented with the same clinical case experiences; therefore, a resident may not have an opportunity within the clinical environment to demonstrate some of the characteristics encompassed within the Milestones. The use of simulation, standardized patients, and other nonclinical assessments will likely grow in importance as methods for evaluating resident performance in some areas. The Milestone process will be helpful in assessing resident progression during training and the need for remediation when a resident is not progressing through a Milestone. At the same time, the Milestone process may be helpful in evaluating the effectiveness of and role for these alternative training methods in identifying areas of weakness.The adoption of Milestones in resident assessment will advance the journey toward competency-based graduate medical education that began with the Outcomes Project. Yet with this advance comes additional challenges. Once well-defined Milestones are fully integrated into residency education, it will be necessary to reconcile competency-based end points of training with the variable rate at which Level 4 Milestones will be reached by individual residents. Resolving this dilemma will provide opportunities for innovation in future training paradigms.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project has shifted the focus for accrediting residency training programs from structure and process to documented outcomes. A central part of the ACGME's Next Accreditation System (NAS) is “articulating milestones of competency development in each discipline.”1 Resident achievement of educational Milestones will be an indicator of the educational effectiveness of residency programs. Most specialties have developed their Milestones through a collaborative effort involving representatives from the ACGME, the pertinent American Board of Medical Specialties (ABMS) organization, the pertinent professional specialty society, and the pertinent program directors' association. In contrast, the approach was quite different for Transitional Year (TY) residency programs, which comprise only 1 year of accredited postgraduate medical education, where there is no corresponding ABMS board certification entity or professional specialty society. In addition, graduates of TY training programs are not expected to demonstrate sufficient competency to enter the independent practice of medicine, as is the case with other specialty (categorical) residency programs.

Fellowship Training in Adult Cardiothoracic Anesthesiology: Navigating the New Educational Landscape as a Result of the Coronavirus Crisis

The Road Ahead

How To Maximize Trainee Education During the Coronavirus Disease-2019 Pandemic: Perspectives From Around the World

Roe v Wade, Dobbs, and the Future of Graduate Medical Education.

Training Directors Have Positive Perceptions of a Competency-Based Gastroenterology and Transplant Hepatology Fellowship Program

Integrative Hematology Oncology Fellowship: A Descriptive Analysis of the First Accredited Program in the United States

Accredited training programs in clinical neurophysiology (CNP) and individual certification in the subspecialty of Clinical Neurophysiology have been available for about 5 years. We review the current status of CNP training and certification to provide an overview of CNP certification. The accreditation of CNP training programs was established to monitor the quality of the training of neurologists who have a major commitment to the practice of CNP. The Accreditation Council for Graduate Medical Education (ACGME) approved the CNP training program requirements in 1993 on the recommendation of the Neurology Residency Review Committee (RRC). The CNP program requirements were updated recently by the RRC, to become effective January 2001, and are posted on the ACGME Web site (www.ACGME.org). CNP training programs have been accredited since 1995 with a total of 76 now accredited among the 117 accredited core neurology programs. A number of additional programs are being accredited each year. The American Board of Medical Specialties (ABMS) approved Clinical Neurophysiology as an added qualification certification in 1990 under the aegis of the American Board of Psychiatry and Neurology (ABPN). The first CNP examination was given in 1992 with required recertification in 10 years. Since then, 1588 candidates have taken the CNP subspecialty certification examination and 1211 have been certified. As of the year 2000, 1 year of CNP training in an accredited program is required to take the certification examination. The next examination is being given on April 3, 2001. Applications had to be submitted by September 30, 2000. The examination is given biannually and the subsequent opportunity to take this examination will be in the spring of 2003. Applications need to be submitted by the early autumn of 2002. Accredited, core neurology training programs provide education and experience in each of the subspecialty areas in neurology, such as movement disorders, …

The Accreditation Council for Graduate Medical Education (ACGME) is encouraging medical residency programs to objectively assess their trainees for possession of six general clinical competencies by the completion of residency training. This is the thrust of the ACGME Outcome Project, now in its seventh year. As residency programs seek to integrate the general competencies into clinical training, educators have begun to suggest that objective assessment of clinical competence may be able to guide decisions about length of training and timing of subspecialization. The authors contend that higher-level competence is not amenable to assessment by the objective comparison of resident performance with learning objectives, even if such objectives are derived from general competencies. Present-day attempts at such assessment echo the uses to which medical schools hoped to put curricular learning objectives in the 1970s. Objective assessment may capture knowledge and skills that amount to the "building blocks" of competence, but it cannot elucidate or scrutinize higher-level clinical competence. Higher-level competence involves sensitivity to clinical context and can be validly appraised only in such a context by fully competent clinical appraisers. Such assessment is necessarily subjective, but it need not be unreproducible if raters are trained and if sampling of trainee performance is sufficiently extensive. If the ACGME approach to clinical competency is indeed brought to bear on decisions about training length and subspecialization timing, the present apprenticeship model for clinical training in the United States, a model both remarkably successful and directly descendant from Osler's innovations, will be under threat.