Education and Certification of Fellows: The Tyranny of Time

Abstract

* Abbreviation: EPA — : entrustable professional activity Within this compendium of perspectives and expert consensus about the education of subspecialty fellows, we are told that “ Recent advances in medical education allow the question of required duration of training to be examined using the metric of the pediatrics milestones.…” The consensus also reinforces that “Training should remain at three years for now, but over time the Board could allow a shorter or longer period to demonstrate expertise in a particular subspecialty. ” 1 Here we have the setting for 2 fundamental, but potentially conflicting, metrics, time versus maturation, that can collide and put substantial strain on resources intended to educate and certify fellows. If time is used as the gating mechanism for the advancement of fellows, it stands to reason that there will be heterogeneity of skills, knowledge, and maturity upon completion of the requisite time. Alternatively, if maturation is used as the gating mechanism, then there will likely be heterogeneity in the time to completion. It is worth exploring some of the consequences of these options. To the extent that the milestones (such as the Denver Developmental Screening Test) and entrustable professional activities (EPAs; such as the driver’s road test) will provide a blueprint for assessing the maturation of a fellow, the potential benefit is a rigorous, reproducible, and logical method to recognize what competencies have been achieved throughout the course of education and clinical practice. In addition, this method should provide a means to track a fellow’s progress in real time, which would permit formative feedback and potential for midcourse adjustments and, even more importantly, for self-directed learning and development. This approach requires validation of the evaluation, establishment of confidence intervals, measurement of interrater agreement, certainty that the maturational schema is properly ordered, and assessment of ease of application. It is essential to recognize that … Address correspondence to George Lister, MD, Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064. E-mail: george.lister{at}yale.edu