Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process.

BACKGROUND AND OBJECTIVES: Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones. METHODS: We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones. RESULTS: The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%). CONCLUSIONS: Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

A statement on the current status and future needs of the pediatric pulmonology workforce: Pipeline Workgroup.

There is growing concern that current trends in pediatric pulmonology will lead to a workforce shortage resulting in patients having difficulty accessing subspecialty care. As part of the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association Workforce Summit, we examined factors affecting the recruitment of learners into pediatric pulmonary fellowship training (PPFT) programs. The goal of our workgroup was to describe these issues and develop a plan to increase the pipeline of learners who ultimately pursue PPFT. Specifically, we summarize factors that impact decisions to undertake PPFT, describe existing initiatives to enhance recruitment, and propose future strategies to increase early career learner interest.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Scholarly Activity During Pediatric Fellowship.

BACKGROUND AND OBJECTIVES: The educational requirements for pediatric fellows include at least 12 months of scholarly activity and generation of a work product. Yet there lacks detailed guidance on how programs can best integrate scholarly activity training into fellowships. Our objectives were to understand the resources and barriers to training and identify factors associated with productivity. METHODS: We surveyed pediatric fellowship program directors (FPDs) nationally in 2019. Data analysis included descriptive statistics, χ2 and Fisher's exact tests, and multivariable modeling to identify factors associated with high productivity (>75% of fellows in the past 5 years had an article from their fellowship accepted). RESULTS: A total of 499 of 770 FPDs responded (65%). A total of 174 programs (35%) were highly productive. The most frequent major barriers were a lack of funding for fellows to conduct scholarship (21%, n = 105) and lack of sufficient divisional faculty mentorship (16%, n = 79). The median number of months for scholarship with reduced clinical obligations scholarship was 17. A total of 40% (n = 202) of FPDs believed training should be shortened to 2 years for clinically oriented fellows. Programs with a T32 and a FPD with >5 publications in the past 3 years were twice as likely to be productive. Not endorsing lack of adequate Scholarship Oversight Committee expertise and a research curriculum as barriers was associated with increased productivity (odds ratio = 1.83-1.65). CONCLUSIONS: Despite significant protected fellow research time, most fellows do not publish. Ensuring a program culture of research may provide the support needed to take projects to publication. The fellowship community may consider reevaluating the fellowship duration, particularly for those pursing nonresearch focused careers.

Using Appreciative Inquiry to Inform Program Evaluation in Graduate Medical Education.

BACKGROUND: Graduate medical education programs are expected to conduct an annual program evaluation. While general guidelines exist, innovative and feasible approaches to program evaluations may help efforts at program improvement. Appreciative Inquiry is an approach that focuses on successful moments, effective processes, and programs' strengths. OBJECTIVE: We implemented a novel application of Appreciative Inquiry and its 4 phases (Inquire, Imagine, Innovate, and Implement) and demonstrate how it led to meaningful improvements in a pediatric pulmonology fellowship program. METHODS: As part of the Inquire and Imagine phases, the authors developed an interview guide that aligned with Appreciative Inquiry concepts. Two faculty members conducted semistructured interviews with a convenience sample of 11 of 14 fellowship alumni. Interviews were audiotaped, transcribed, and reviewed. A summary of the findings was presented to the Program Evaluation Committee, which then directed the Innovate and Implement phases. RESULTS: Appreciative Inquiry was acceptable to the alumni and feasible with the authors' self-directed learning approach and minimal administrative and financial support. In the Inquire phase, alumni identified program strengths and successes. In the Imagine phase, alumni identified program changes that could aid transition to independent practice for future fellows (an identified program goal). Based on the results of the Appreciative Inquiry, program leadership and the Program Evaluation Committee selected improvements for implementation. CONCLUSIONS: For small programs, Appreciative Inquiry is an innovative and feasible approach to program evaluation that facilitates actionable program improvement recommendations.

Investing in future pediatric subspecialists: a fellowship curriculum that prepares for the transition to academic careers.

BACKGROUND: The experience of transitioning to an academic faculty position can be improved with standardized educational interventions. Although a number of such interventions have been described, few utilize an evaluation framework, describe a robust evaluation process, and address why their interventions were successful. In this article, the authors apply a logic model to describe their efforts to develop, implement, evaluate, and revise a comprehensive academic career development curriculum among pediatric subspecialty fellows. They describe inputs, activities, outputs, and outcomes using quantitative data from fellow evaluations and qualitative data from faculty interviews. METHODS: Methods are described under the input and activities sections. The curriculum started with collaboration among educational leadership and conducting a needs assessment. Using the needs assessment results and targeted learning objectives, we piloted the curriculum and then implemented the full curriculum 1 year later. RESULTS: Results are described under the outputs and outcomes sections. We present immediate, short-term, and 6-month evaluation data. Cumulative data over 3 years reveal that fellows consistently acquired knowledge relevant to transitioning and that they applied acquired knowledge to prepare for finding jobs and career advancement. The curriculum also benefits faculty instructors who gain a sense of reward by filling a critical knowledge gap and fostering fellows' professional growth. CONCLUSION: The authors relate the success and effectiveness of the curriculum to principles of adult learning, and share lessons learned, including the importance of buy-in from junior and senior fellows and faculty, collaboration, and designating the time to teach and learn.