Clinical Competency Committee Research Articles

Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities

A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.

Development of entrustable professional activities for family medicine in South Africa.

South Africa is undergoing a significant shift towards implementing enhanced workplace-based assessment methodologies across various specialist training programmes, including family medicine. This paradigm involves the evaluation of Entrustable Professional Activities (EPAs) through comprehensive portfolios of evidence, which a local and national clinical competency committee then assesses. The initial phase of this transformative journey entails the meticulous development of EPAs rooted in discrete units of work. Each EPA delineates the registrar's level of entrustment for autonomous practice, along with the specific supervision requirements. This concise report details the collaborative effort within the discipline of family medicine in South Africa, culminating in the consensus formation of 22 meticulously crafted EPAs for postgraduate family medicine training. The article intricately outlines the systematic structuring and rationale behind the EPAs, elucidating the iterative process employed in their development. Notably, this marks a groundbreaking milestone as the first comprehensive documentation of EPAs nationally for family medicine training in Africa.

Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs.

The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones. Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings. A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455). Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.

Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future.

Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.

A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees

AbstractIntroductionThe real‐world mechanisms underlying prospective entrustment decision making (PEDM) by entrustment or clinical competency committees (E/CCCs) are poorly understood. To advance understanding in this area, the authors conducted a realist synthesis of the published literature to address the following research question: In E/CCC efforts to make defensible prospective entrustment decisions (PEDs), what works, for whom, under what circumstances and why?MethodsRealist work seeks to understand the contexts (C), mechanisms (M) and outcomes (O) that explain how and why things work (or do not). In the authors' study, contexts included individual E/CCC members, E/CCC structures and processes, and training programmes. The outcome (i.e. desired outcome) was a PED. Mechanisms were a substantial focus of the analysis and informed the core findings. To define a final corpus of 52 included papers, the authors searched four databases, screened all results from those searches and performed a full‐text review of a subset of screened papers. Data extraction focused on developing context–mechanism–outcome configurations from the papers, which were used to create a theory for how PEDM leads to PEDs.ResultsPEDM is often driven by default (non‐deliberate) decision making rather than a deliberate process of deciding whether a trainee should be entrusted or not. When defaulting, some E/CCCs find red flags that sometimes lead to being more deliberate with decision making. E/CCCs that seek to be deliberate describe PEDM that can be effortful (when data are insufficient or incongruent) or effortless (when data are robust and tell a congruent story about a trainee). Both information about trainee trustworthiness and the sufficiency of data about trainee performance influence PEDM. Several moderators influence what is considered to be sufficient data, how trustworthiness data are viewed and how PEDM is carried out. These include perceived consequences and associated risks, E/CCC member trust propensity, E/CCC member personal knowledge of and experience with trainees and E/CCC structures and processes.DiscussionPEDM is rarely deliberate but should be. Data about trainee trustworthiness are foundational to making PEDs. Bias, equity and fairness are nearly absent from the papers in this synthesis, and future efforts must seek to advance understanding and practice regarding the roles of bias, equity and fairness in PEDM.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training.

In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments. Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC). New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation. A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment

BackgroundEntrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one’s abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment.ObjectivesWe hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME).MethodsIn fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale.ResultsOne-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59–0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05).ConclusionsWe found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

User-Centered Evaluation and Design Recommendations for an Internal Medicine Resident Competency Assessment Dashboard.

Clinical Competency Committee (CCC) members employ varied approaches to the review process. This makes the design of a competency assessment dashboard that fits the needs of all members difficult. This work details a user-centered evaluation of a dashboard currently utilized by the Internal Medicine Clinical Competency Committee (IM CCC) at the University of Cincinnati College of Medicine and generated design recommendations. Eleven members of the IM CCC participated in semistructured interviews with the research team. These interviews were recorded and transcribed for analysis. The three design research methods used in this study included process mapping (workflow diagrams), affinity diagramming, and a ranking experiment. Through affinity diagramming, the research team identified and organized opportunities for improvement about the current system expressed by study participants. These areas include a time-consuming preprocessing step, lack of integration of data from multiple sources, and different workflows for each step in the review process. Finally, the research team categorized nine dashboard components based on rankings provided by the participants. We successfully conducted user-centered evaluation of an IM CCC dashboard and generated four recommendations. Programs should integrate quantitative and qualitative feedback, create multiple views to display these data based on user roles, work with designers to create a usable, interpretable dashboard, and develop a strong informatics pipeline to manage the system. To our knowledge, this type of user-centered evaluation has rarely been attempted in the medical education domain. Therefore, this study provides best practices for other residency programs to evaluate current competency assessment tools and to develop new ones.

Association of Interview and Holistic Review Metrics With Resident Performance-Related Difficulties in an Internal Medicine Residency Program.

Background The utility of traditional academic factors to predict residency candidates' performance is unclear. Many programs utilize holistic review processes assessing applicants on an expanded range of application and interview characteristics. Determining which characteristics might predict performance-related difficulty in residency is needed. Objective We aim to elucidate factors associated with residency performance-related difficulty in a large academic internal medicine residency program. Methods In 2022, we conducted a retrospective cohort study of Electronic Residency Application Service and interview data for residents matriculating between 2018 and 2020. The primary outcome was a composite of performance-related difficulty during residency (referral to the Clinical Competency Committee; any rotation evaluation score of 2 out of 5 or lower; and/or a confidential "comment of concern" to the program director). Logistic regression models were fit to assess associations between resident characteristics and the composite outcome. Results Thirty-eight of 117 residents met the composite outcome. Gold Humanism Honor Society (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.16-0.87) or Alpha Omega Alpha (OR 0.36, 95% CI 0.14-0.99) members were less likely to have performance-related difficulty, as were residents with higher United States Medical Licensing Examination Step 2 Clinical Knowledge scores (OR 0.97, 95% CI 0.47-1.00). One-point increases in general faculty overall interview score, leadership competency score, and leadership overall score were associated with 41% to 63% lower odds of meeting the composite outcome. Interview or file review "flags" had an OR of 2.82 (95% CI 1.37-5.80) for the composite outcome. Conclusions Seven metrics were associated with the composite outcome of resident performance-related difficulty.

Using Theory-Informed Group Processes to Make TIMELESS Promotion Decisions.

Competency-based medical education (CBME) depends on effective programs of assessment to achieve the desired outcomes and goals of training. Residency programs must be able to defend clinical competency committee (CCC) group decisions about learner readiness for practice, including decisions about time-variable resident promotion and graduation. In this article, the authors describe why CCC group decision-making processes should be supported by theory and review 3 theories they used in designing their group processes: social decision scheme theory, functional theory, and wisdom of crowds. They describe how these theories were applied in a competency-based, time-variable training pilot-Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS) at the University of Cincinnati internal medicine residency program in 2020-2022-to increase the defensibility of their CCC group decision-making. This work serves as an example of how use of theory can bolster validity arguments supporting group decisions about resident readiness for practice.

Enhancing the Value of Surgical Entrustable Professional Activities through Integrative Learning Analytics

To demonstrate the value of integrating surgical resident Entrustable Professional Activity (EPA) data into a learning analytics platform that provides meaningful feedback for formative and summative decision-making. Description of the Surgical Entrustable Professional Activities (SEPA) analytics dashboard, and examples of summary analytics and intuitive display features. Department of Surgery, University of Wisconsin Hospital and Clinics. Surgery residents, faculty, and residency program administrators. We outline the major functionalities of the SEPA dashboard and offer concrete examples of how these features are utilized by various stakeholders to support progressive entrustment decisions for surgical residents. Our intuitive analytics platform allows for seamless integration of SEPA microassessment data to support Clinical Competency Committee (CCC) decisions for resident evaluation and provides point of training feedback to faculty and trainees in support of progressive autonomy.

Differences in Resident Self-Evaluation and Clinical Competency Committee Evaluation Using ACGME Milestone Versions 1.0 and 2.0

Intentionally self-driven professional development of surgical resident physicians is a hallmark of surgical training and is expected to gain further traction as Entrustable Professional Activities (EPAs) become the new paradigm for surgical education. We aimed to analyze how surgical residents rate themselves as compared to the evaluation of the Clinical Competency Committee using ACGME Milestones Version 1 (M1.0) and Version 2 (M2.0). We asked 22 general surgical trainees for self-evaluation of Milestones (both M1.0 and M2.0) from 2017 semiannually to 2022. ACGME-required Milestone evaluations by the Clinical Competency Committee (CCC) were independently performed after the time window for resident self-evaluation. Neither trainees nor CCC were aware of the other party's evaluations. There were 1552 paired data available for evaluating individual competencies by both trainees and CCC. Paired Wilcoxon signed-rank tests were then performed among the corresponding pairs. MercyOne Des Moines Medical Center, Des Moines, IA; Teaching tertiary referral center. Twenty-two general surgical trainees at this hospital and 28 faculty surgeons participated in this study. The average self-evaluation of surgical residents was lower in the M1.0 cohort compared to the corresponding CCC evaluation (1.96 ± 0.72 vs. 2.11 ± 0.67; p < 0.001). M1.0 self-assessments and CCC-assessments were statistically similar for ICS (p = 0.548) and PROF (p = 0.554) competencies and differed for MK (p < 0.001), PBLI (p < 0.001), PC (p < 0.001), SBP (p = 0.008). On the contrary, the M2.0 cohort demonstrated higher average self-evaluation of surgical residents compared to the corresponding CCC evaluation (2.75 ± 0.87 vs. 2.12 ± 0.97; p < 0.001). Significant differences were observed for all 6 ACGME competencies using M2.0 self-assessments and CCC-assessments (all p < 0.001). Multivariate regression modeling (p < 0.001, R2 = 0.255) predicted the degree of discordance between self-assessment and CCC-assessed achievement of competencies with a significant effect of gender (baseline male: coef = -0.232, p < 0.001), PGY level (-0.083 per year, p < 0.001) and Milestone version (0.831, p < 0.001). A significant interaction exists for all gender/Milestone combinations except for the female trainees with M1.0. The difference between self-evaluated Milestone achievement and faculty-driven CCC evaluation of surgical resident physician performance is more evident in Milestones 2.0 than in Milestones 1.0. Residents self-evaluate higher compared to faculty using Milestones 2.0. This discrepancy is seen among both genders and is more pronounced among male residents overestimating core competencies with M2.0 self-evaluation than formal CCC assessment.

Features of Effective Clinical Competency Committees.

The Clinical Competency Committee (CCC) provides accountability to the general public that physicians completing a training program have achieved competence. CCC processes and features that best identify resident outcomes along a developmental spectrum are not well described. This study sought to describe CCC features associated with effective and efficient CCC performance. The study was conducted as part of the 2022 Council of Academic Family Medicine Educational Research Alliance survey of family medicine residency program directors. The survey assessed CCC methods, policies, faculty development, structure, and overall CCC time required. The outcomes were identification of residents along a spectrum of development, from failing to exceeding expectations. Ordinal logistic regressions were used to explore the relationship between CCC characteristics and CCC outcomes. The response rate was 43.3% (291 of 672). Eighty-nine percent (258 of 291) of program directors reported their CCC is successful in identifying residents not meeting expectations; 69.3% (201 of 290) agree their CCC identifies residents who are exceeding expectations. Programs with written policies for synthesizing data (OR=2.53; 95% CI 1.22-5.22; P=.012) and written policies for resident feedback (OR=19.91; 95% CI 3.72-106.44; P<.001) were more likely to report successfully identifying residents below expectations. Programs whose members spent fewer than 3 hours per 6-month interval on CCC meetings were less likely to report being able to identify failing residents (OR=0.37; 95% CI 0.19-0.72; P=.004). This survey of family medicine program directors suggests that formal policies, faculty development, and adequate time for CCC faculty are associated with an effective CCC, especially if goals beyond "identifying failure" are desired.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Group Decision Making in Competency-Based Medical Education - Clinical Competency Committee

&lt;p&gt;臨床能力委員會(Clinical Competency Committee, CCC)在勝任能力導向醫學教育的總結性評量中扮演重要的角色。委員會根據以評量藍圖執行的職場觀察評量結果，進行系統性的討論，對學員的能力進展做出公正可靠的判斷，回饋給相關利害關係人，並協助學員擬定個人化之補強訓練計畫。進行會議前應有共識會議、師資培育課程、及學員能力進展資料閱讀，事前的學員自我評量能夠促進學員與教師對學員能力進展的認知，並促進學員對於教師回饋的接納理解程度；會議中須建立結構化的決策過程，最終獲得客觀且可信的決策成果；會議後應向學員提供回饋，並協助制訂補強學習計畫或提供訓練協助規劃。藉由完善的CCC程序，可提升臨床醫事人員的訓練品質、教師教學水準、醫療服務品質及專業認同。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Clinical Competency Committee (CCC) plays a key role in the summative assessment of competency-based medical education (CBME). Specifically, CCC conducts systematic discussions according to the results of workplace observation and assessment derived from assessment blueprints to provide an accountable and reliable judgment on the progression of trainees&amp;rsquo; competencies. CCC then informs assessment results to stakeholders and assists trainees in developing personalized remedial learning plans. CCC members should conduct a consensus meeting, complete faculty training courses, and review trainees&amp;rsquo; competency development data before calling a CCC meeting . Student self-assessment should also be completed before the CCC meeting to improve trainees&amp;rsquo; and CCC members&amp;rsquo; understanding of the progress of their competency development and to ensure that trainees agree with and accept teachers&amp;rsquo; feedback. During the CCC meeting, a structured decision-making procedure must be constructed for objective and credible decision-making. After the meeting, feedback should be provided to students to assist them in developing remedial learning plans or training assistance plans. A comprehensive group decision-making procedure should be carried out in CCC to improve the quality of clinical staff training, teaching, and medical services as well as the professional identity of clinical staff.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

A novel 6-day cycle surgical pathology rotation improves resident satisfaction and maintains Accreditation Council for Graduate Medical Education (ACGME) milestone performance

Surgical pathology residency training in the United States lags behind other specialties in quality control and graduated responsibility to train independent pathologists capable of seamlessly entering practice after training. We observed that our traditional 3-day-cycle surgical pathology cycle (day 1–grossing; day 2 –biopsies/frozens/preview; day 3 – sign-out) consistently and negatively impacted resident education by reducing preview time, case follow-up, immunohistochemical stain (IHC) interpretation, and molecular study integration. We aimed to create a modern surgical pathology rotation that improved performance and outcomes. We innovated our rotation to enhance resident education and ensure graduated responsibility. A novel 6-day cycle was created composed of 2 grossing days, 1 frozens/biopsies/preview days, 2 dedicated sign-out days, and 1 frozens/biopsies/case completion day. Residents completed surveys before implementing the new rotation and 6 months after implementation to track self-assessment of Accreditation Council for Graduate Medical Education (ACGME) milestone performance and internal quality control metrics. Clinical Competency Committee (CCC) annual evaluations were assessed in paired PGY levels pre- and post-intervention. After implementation, there was a statistically significant improvement in self-assessment of levels 4 and 5 of ACGME milestones and improved satisfaction of quality metrics, including time for previewing, reviewing IHC, graduated responsibility, and perceived readiness for independent practice. CCC evaluations showed overall maintained performance levels, with trends towards improvements in junior resident classes. Our 6-day cycle adequately fulfills the current demands of our sizeable academic center's surgical pathology training and can be a model for pathology residencies looking to modernize their surgical pathology rotations and resident education.

Comparison of internal medicine applicant and resident characteristics with performance on ACGME milestones

ABSTRACT Internal medicine (IM) residency programs select applicants based on several metrics. Factors predicting success during residency are unclear across studies. To identify whether specific applicant or resident factors are associated with IM resident performance using ACGME milestones. We tested for associations between applicant factors available prior to the start of IM residency and resident factors measured during IM residency training, and resident performance on ACGME milestones across three consecutive years of IM training between 2015-2020. Univariable and multivariable linear regression modeling was used to test associations. Eighty-nine categorical IM residents that completed 3 consecutive years of training were included. Median age was 28 years (IQR 27-29) and 59.6% were male. Mean ACGME milestone scores increased with each post-graduate year (PGY) from 3.36 (SD 0.19) for PGY-1, to 3.80 (SD 0.15) for PGY-2, to 4.14 (SD 0.15) for PGY-3. Univariable modeling suggested referral to the clinical competency committee (CCC) for professionalism concerns was negatively associated with resident performance during each PGY. No applicant or resident factors included in the final multivariable regression models (age at starting residency, USMLE Step scores, interview score, rank list position, ITE scores) were associated with ACGME milestone scores for PGY-1 and PGY-2. Referral to the CCC for professionalism was negatively associated with resident performance during PGY-3. Residency selection factors did not predict resident milestone evaluation scores. Referral to the CCC was associated with significantly worse resident evaluation scores, suggesting professionalism may correlate with clinical performance.

Resident Self-assessment and Clinical Competency Committee Evaluations in Family Medicine: A Single-Institution Study.

We sought to describe the process of integrating resident self-assessments into milestone assessments at the University of Texas Medical Branch Family Medicine Residency Program in Galveston, Texas. We compared resident self-assessments across milestones to Clinical Competency Committee (CCC) assessments across terms (fall versus spring) and by postgraduate year (PGY). In fall 2020, the milestone assessment process was updated to include a resident milestone self-assessment, which was used as the starting point for CCC assessment. We calculated mean and standard deviation of average milestone scores for both self-assessment and CCC for each PGY. We used repeated measure analysis of variance to examine within- and between-subject effects. Self-assessment and CCC assessments were completed for 30 postgraduate trainees for spring 2020 and fall 2021 terms, for a total of 60 self- and 60 CCC assessments. CCC score was similar to self-assessment. There were larger variations in the resident self-assessment scores than CCC scores. Self-assessment scores increased by PGY, but were not different between fall and spring terms. We found a significant three-way interaction of assessors, terms, and PGYs. Resident milestone self-assessment enables residents to participate in the assessment process, and when differences exist between self- and CCC assessments, specific feedback can be given based on individual milestone skills. Our study showed progression between PGY regardless of the assessor, but only CCC assessment showed significant differences between terms.

Milestones Next Steps: Results of a Feedback Questionnaire

The Milestones Development team at the Accreditation Council for Graduate Medical Education (ACGME) has periodically surveyed the graduate medical education (GME) community and volunteers, during and after development of the specialty-specific Milestones 2.0, to check with members of each specialty on the implementation of the new Milestones. As we approached the conclusion of Milestones 2.0 development, it was decided to have broader survey dissemination for all specialties. Although still only 10 questions, 2 major changes were made to the quality assurance feedback questionnaire: (1) It solicited comments and impressions from the approximately 26 000-member email distribution list that receives the ACGME e-communications rather than only those who volunteer to be respondents; and (2) It had a more summative focus meant to be the start of the upcoming program evaluation stage of Milestones, rather than soliciting formative input for any further changes to Milestones 2.0. The survey was open for 6 weeks in the fall of 2022 and resulted in 215 responses, which, after clearing the data of collection errors and detectable duplications, produced 211 valid responses from 27 specialties across the GME community. At the time of distribution, email and survey tracking metrics were not available to produce a meaningful response rate. Respondents provided general descriptions of their specialties and specific roles, their program enrollment, and the membership of their Clinical Competency Committees (CCCs). They were then asked open-ended questions that allowed them to describe any challenges with Milestones 2.0 and to make suggestions for the program as a whole. The intent of this 10-item questionnaire was to collect data that will direct conversations on change and help guide this first step, as well as further program evaluation projects that explore the relationships between Milestones and the GME community. The results of the qualitative analysis of this questionnaire are based on those who chose to respond to the ACGME e-communication request for feedback. The subsequent findings should not be generalized to the GME community or be made to represent thoughts or reactions of any subpopulation therein.Of 211 valid responses, roughly half (n=105, 49.8%) identified as program directors (Table 1) from a dropdown list of options (Question [Q]3), and 46 (21.8%) indicated that they were their CCC chair (Q4). The most represented ACGME core specialties (Q1) were internal medicine (n=46, 21.8%), family medicine (n=35, 16.6%), pediatrics (n=24, 11.4%), and surgery (n=17, 8.1%). Additionally, 80 (37.9%) respondents self-identified a subspecialty (Q2) in the open text question following the specialty question.The responses to (Q5) “Indicate the number of residents or fellows you are currently assessing in your program using the Milestones” ranged from 2 to 170. This question was asked to obtain an approximate number of residents and fellows being assessed, and it was beyond the purview of this project to check a respondent's accuracy regarding this data point.When asked to describe the roles within their current CCC membership (Q6), 181 (85.8%) of the respondents listed their committee as having a program director, 162 (76.8%) indicated a program coordinator, 161 (76.3%) listed an assistant or associate program director, and 199 (94.3%) specified a core faculty member (Table 2). While the survey question had a “public member” option, no respondents indicated as such.Two open-ended questions guided the major focus of the survey: (Q8) “Indicate any challenges you have experienced with Milestones 2.0, or related concerns,” and (Q9) “What changes or resources would you like to see in the Milestones?” Finally, respondents could self-identify under (Q10) “Enter your email and full name to be notified of future Milestones feedback opportunities,” which produced a list of volunteers for future research projects.Researchers from the Milestones department used emergent, in vivo coding to categorize the open-ended responses describing challenges and providing suggestions. While responses reflected specific and individual experiences, some patterns emerged from similar data during analysis that helped paint a picture of the challenges facing the GME community around Milestones. Guided by a heuristic inquiry methodology, the research team performed the coding in the MAXQDA software (VERBI Software GmbH) to label the open-ended responses and look for the patterns using a constant comparative analysis approach.1 The most prevalent challenges and suggestions are discussed below with exact verbiage lifted from the responses.The first prominent idea uncovered in the response data involved faculty use and interpretation of the Milestones. Particularly, many respondents mentioned faculty not being fully invested in the Milestones as an assessment tool and that faculty may consider the goals of the Milestones as too lofty or unachievable.Another common topic from the data highlighted issues with specific subcompetencies, namely those that measure advocacy or well-being. Some respondents called out a few Milestones that were difficult to observe as well as directly assess, particularly those speaking to system management and the physician role in the health care system. Similarly, there were comments that described the Milestones as being too vague or subjective and too difficult to transfer to the provided scale. One comment stated: “Based on how these are worded many of our residents hit a level 3 at PGY-2 and then stay there despite continuing to improve in their abilities.” (internal medicine)Data also reflected issues with the amount of time required to adequately assess residents and fellows on each Milestones subcomeptency. This may be related to other comments where respondents felt there were too many Milestones to assess or that the Milestones were too long or wordy. “Too many Milestones! Takes way too long to complete them twice a year for all of our residents.” (diagnostic radiology)Some respondents described challenges with transitioning from Milestones 1.0 to 2.0, such as making adjustments to their assessment practices and software tools to reflect the changes. One comment pointed out that it would get easier: “There are some that don't correlate perfectly with the new milestones, so this made tracking resident improvement over time difficult. This should get easier once we use the 2.0 version for all 3 resident years.” (pediatrics)There were also a few respondents who felt as though the Milestones were not applicable to actual clinical practices. For example: “I find the wording of the Milestones 2.0 incredibly hard to apply to real world resident performance.” (internal medicine) and “The verbiage is still extremely convoluted and often does not apply to real life.” (family medicine) Others indicated that the Milestones do not capture the context of the resident's “rotation experience.” (family medicine)Similarly, data from the survey described issues with few opportunities for residents to be assessed or actually observed within specific Milestones contexts. They also spoke of other challenges: “Bias from prior milestone evaluations. Some CCC members may evaluate residents that they have not personally worked with over the past 6 months.” (surgery–surgical oncology) and “Finding ways for residents to achieve, and for us to observe and document, some milestones elements (ex. SBP2, SBP3, PROF1, ICS1), especially those in the upper levels.” (pathology–surgical pathology)There remained some responses that did not fall into a particular pattern or theme but still highlighted concerns worth mentioning:The survey respondents' suggestions were just as varied as their challenges, but some themes were evident. The most prominent area for suggestions centered around the need for clearer applications and more examples for the Milestones levels, either beyond the existing supplemental guidebooks or an updated version of them.Another common thread among the suggested changes was the inclusion of either additional Milestones or a new focus reflected within Milestones. Particularly, these responses spoke to skills development in leadership, teaching, and scholarly activities.Respondents also focused their suggestions on language simplification and applying more realistic language as well as condensing Milestones, making them shorter or even reducing the overall number of them.Another theme identified the need for more faculty development and education that address “goals, changes, and interventions to address failure to progress.” (surgery–acute care surgery) Responses also spoke to the need for evaluation forms that would be easy to use and implement into the learner's record automatically. Some respondents suggested using the Milestones as the assessment tool: “Evaluation tools would be helpful, not just the milestones but also some suggested way to assess. Or just let us use the milestones as assessment tools, because the rubrics are built out well enough now that they could be used as direct assessments.” (anesthesiology)Individual comments spoke to a wide variety of suggestions, such as the following:This survey was developed to collect general, voluntary feedback with only 2 focused questions for challenges and suggestions as an early look informing program evaluation for Milestones. While the data are not representative of any group or subgroup within GME, the broad and organic analysis shows that the GME community feels that the Milestones program should continue its focus on providing a transparent and concise assessment tool that does not overburden faculty, program directors, or the residents and fellows.2-5 The survey results also indicate the need to reiterate the validity of the Milestones assessments in the harmonized competencies as well as in patient care and medical knowledge.6,7 There is evidence supporting more emphasis on developing a concerted effort by faculty and CCCs to utilize the tools and resources that the Milestones program provides. Some survey respondents also expressed the need for Milestones to continue efforts for developing subcompetencies that could integrate with other specialty-specific assessment tools.The Milestones department has already researched and taken steps to provide GME faculty with access to resources, such as guidebooks (Milestones, CCCs, assessment, etc) and faculty development courses,8,9 and currently offers periodic courses to address faculty understanding and usage of the Milestones assessments. The department also has developed supplemental resources and has explained the rigor that goes into developing the validity and reliability of the tools.10 The data also spoke to the importance of keeping current and future resources visible, available, and accessible to the GME community.The ACGME Milestones team would like to thank those who took part in the survey and provided their valuable feedback. The resulting suggestions and conversations will give the Milestones department the foundations to better inform their upcoming evaluation research on the Milestones program. Over the next few years an intensive review of the Milestones will occur. This research will delve into the development process, content, and implementation within programs. Data will be collected through focus groups, interviews, content analyses, and targeted surveys. If you are interested in sharing your opinion, please send an email with your name, specialty, and/or subspecialty to MilestonesQA@acgme.org.

Reimagining Gastroenterology Fellowship Training: The Third Year of the Future

Implementing change in medical education is increasingly being recognized as an opportunity “to best address the workplace needs of our current and future health care system.”1Kaplan G.S. Meier C.A. Zimlichman E. et al.Designing the health care workforce of the future.NEJM Catalyst. 2022; 3: 1-11Google Scholar Capable physicians provide safe, equitable, and patient-centered care. They adjust to changing clinical practice climates, work and communicate professionally in teams, critically appraise their performance, receive constructive feedback, and engage in self-reflection.2Lucey C.R. Thibault G.E. Ten Cate O. Competency-based, time-variable education in the health professions: crossroads.Acad Med. 2018; 93: S1-S5Crossref PubMed Google Scholar Competency-based education has been gaining momentum worldwide since the 1990s,3Ten Cate O. Competency-based postgraduate medical education: past, present and future.GMS J Med Educ. 2017; 34: Doc69PubMed Google Scholar but the implementation of the framework has varied widely. The framework gives fellows who demonstrate early competence the opportunity to personalize and enrich their training during the third year of fellowship in ways that meaningfully contribute to their future goals as gastroenterologists and hepatologists. In this review, we aim to summarize the perspectives presented at the “Third Year of the Future” session sponsored by the American Gastroenterological Association (AGA) Education & Training Committee and presented in symposium format at Digestive Diseases Week 2022. This integrated summary presents the consensus developed during the session. General gastroenterological (GI) training is prerequisite for individualized training and career paths. The first year of fellowship should focus on general clinical and research exposure, understanding that the niche identified by a resident starting fellowship may be a stronger reflection of mentorship available through their residency program than their true passion. To facilitate career development, first-year fellows should meet with potential mentors, gain broad exposure to available career paths, and explore their personal values and strengths. The second year of fellowship should continue to focus on enhancing skill sets and overall subspecialty-related clinical competence. During this time, program leadership should actively engage trainees in meaningful feedback and reflection, so that they are better able to identify areas of potential growth and work to develop their skills in these domains. Clinical competency committees should use Entrustable Professional Activities and/or milestones to guide decisions about competence; these decisions should be made collaboratively based on a fellow’s individual goals and the basic requirements for all graduating GI trainees. Dedicated efforts to expose fellows to GI outside of clinical practice should be made. Possible areas of exposure include leadership skills, practice management and health care finance, quality improvement and patient safety, medical education, diversity, global health, and health equity. Fellows should consider the impact of these interests on their professional identity development. Throughout the first 2 years of fellowship, mentors should foster self-leadership by helping trainees to envision their futures, asking questions that allow them to think freely and without judgment (Supplementary Figure 1). Based on these discussions, mentors and program directors can help fellows to plan for optional specialized training pathways in the third year of fellowship based on their ultimate career goals. Potential career pathways are depicted in Figure 1. Personalized training tracks offered in the third year should be available to fellows who have demonstrated competence in acquiring general GI skills in the preceding 2 years. These opportunities allow fellows to develop a niche, which may be clinical or nonclinical based on their goals. Learning experiences may involve participation in subspecialty clinics, the development of specific endoscopy skills, or engaging in scholarly projects aligned with the niche. Specialized endoscopy training can be acquired through simulation, hands-on workshops, observation at high-volume centers, industry-supported in-service sessions, and video-based learning. For example, a trainee seeking expertise in inflammatory bowel disease may engage in elective rotations in colorectal surgery, radiology, and visiting rotations sponsored by the Crohn’s and Colitis Foundation. Potential specialized clinical training tracks are outlined in Supplementary Figure 2. Some interests, such as transplant hepatology or advanced endoscopy, require a fourth year of clinical training at the conclusion of the traditional GI fellowship.4American Association for the Study of Liver DiseasesHepatology training pathways. American Association for the Study of Liver Diseases, Alexandria, VA2022Google Scholar,5American Society for Gastrointestinal EndoscopyAdvanced Endoscopy Fellowship. American Society for Gastrointestinal Endoscopy, Downer’s Grove, IL2022Google Scholar Some subspecialties have industry- or organizational-sponsored rotations that give fellows the opportunity to directly learn from experts outside their home institutions. Ideally, sponsored tracks will evolve to include nontraditional partnerships with nonprofit public health services, insurers, or even government programs. Regardless of clinical pathway, fellows who have demonstrated competence would benefit from graded supervision, in which they are granted increased autonomy based on their clinical competence.6Goldhamer M.E.J. Martinez-Lage M. Black-Schaffer W.S. et al.Reimagining the clinical competency committee to enhance education and prepare for competency-based time-variable advancement.J Gen Intern Med. 2022; 37: 2280-2290Crossref PubMed Scopus (3) Google Scholar Promotion-in-place has been shown to improve trainee self-assessment, as well as program assessment of all trainees, not just those who perform below the expected standard.6Goldhamer M.E.J. Martinez-Lage M. Black-Schaffer W.S. et al.Reimagining the clinical competency committee to enhance education and prepare for competency-based time-variable advancement.J Gen Intern Med. 2022; 37: 2280-2290Crossref PubMed Scopus (3) Google Scholar Increased autonomy will more closely mimic the eventual practice environments of our graduates, which provides a safety net for trainees to troubleshoot independently in systems-based practice.7Halpern S.D. Detsky A.S. Graded autonomy in medical education—managing things that go bump in the night.N Engl J Med. 2014; 370: 1086-1089Crossref PubMed Scopus (47) Google Scholar Capable physicians possess skills and knowledge that extend beyond patient care. This includes an ability to identify the current health care context and improve patient care based on assessment of both systems and personal performance. In many ways, the needs of the health system are linked to the evolution of these competencies.8Frenk J. Chen L. Bhutta Z.A. et al.Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.Lancet. 2010; 376: 1923-1958Abstract Full Text Full Text PDF PubMed Scopus (3043) Google Scholar Examples of these needs are depicted in Figure 2. To be successful, fellows must be exposed to nonclinical activities that build knowledge and skill across a variety of domains, including emotional intelligence, change management, negotiation, and conflict resolution.9Stoller J.K. Leadership essentials for CHEST medicine professionals: models, attributes, and styles.Chest. 2021; 159: 1147-1154Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar To achieve this, some trainees will pursue additional degrees during training, such as a graduate degree (eg, MBA, MHA, MPH), certificate, or a specialized track that builds self-efficacy in these domains. Examples of this needs-driven evolution include advocacy, diversity, health systems science, health care finance, and leadership. The increasing complexity of reimbursement, rising insurance premiums, and the emergence of telehealth have highlighted the need for advocacy in our field. Special attention to diversity, equity, and inclusion, as it pertains to both patient care and our physician workforce, has rapidly emerged as an unmet need within GI.10Cryer B. Quezada S. Culpepper-Morgan J.A. et al.Bridging the racial, ethnic, and gender gap in gastroenterology.Gastroenterology. 2022; 163: 800-805Abstract Full Text Full Text PDF PubMed Google Scholar Last, the importance of resonant health care leadership has grown as physician well-being and prevention of burnout are more regularly prioritized.9Stoller J.K. Leadership essentials for CHEST medicine professionals: models, attributes, and styles.Chest. 2021; 159: 1147-1154Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Successful individualized training is rooted in strong self-assessment and mentorship. The goal of a reimagined fellowship is not only to meet the needs of the changing health system, but also to cultivate trainees with a greater sense of their professional identity at the time of graduation. Professional identity development begins with the trainee’s vision for their future self, both personally and professionally. Programs should make routine use of individualized learning plans (ILPs) that are updated and shared with a mentor at least annually. ILPs give fellows the chance to prioritize their short- and long-term goals in accordance with their overarching vision.11Bhavsar-Burke I. Dilly C.K. Oxentenko A.S. How to promote professional identity development and support fellows-in-training through teaching, coaching, mentorship, and sponsorship.Clin Gastroenterol Hepatol. 2022; 20: 2166-2169Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Continued reference to ILPs and course readjustment based on stated goals provides fellows with the foundational skills required for self-assessment. ILPs also help mentors to guide fellows in choosing which opportunities are best aligned with their goals.11Bhavsar-Burke I. Dilly C.K. Oxentenko A.S. How to promote professional identity development and support fellows-in-training through teaching, coaching, mentorship, and sponsorship.Clin Gastroenterol Hepatol. 2022; 20: 2166-2169Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar These opportunities could include formal teaching activities with medical students and residents, informatics training, or exposure to palliative care. Procedural training in the third year can also be adapted to meet the specific needs of each fellow, depending on their chosen clinical practice. For example, if a fellow is joining a practice that lacks anorectal motility expertise, then they may train to competence in anorectal manometry and do additional anorectal clinics. It is our responsibility to recognize that our fellows may be served by teachers and mentors outside our divisions when considering these topics, and we should foster interdisciplinary relationships across our institutions to meet these evolving needs. Program directors should be prepared to identify divisional and institutional stakeholders in key nonclinical areas that can serve as mentors to their trainees. Moreover, they can refer fellows to opportunities within professional societies; examples include AGA’s Connections Corner or Career Compass, quality improvement training through the Institute for Health Care Improvement, and national society-based committee service to build skills and network.12Cataldi M.L. Kelly-Hedrick M. Nanavati J. et al.Post-residency medical education fellowships: a scoping review.Med Educ Online. 2021; 261920084Crossref PubMed Scopus (2) Google Scholar To implement the third year of the future, programs and institutions will need to commit to creating a schedule that is inherently flexible in the third year of training. Flexibility in clinical training programs may not seem feasible owing to the clinical demands placed on the fellows in many programs. We must acknowledge this reality and work with our institutions to create programs and solutions that better serve both our immediate and future needs. In addition, new clinical experiences will need to be incorporated. The current focus tends to be on inpatient consult services; however, the physician of the future may benefit from a greater emphasis on outpatient experiences, endoscopy in ambulatory surgical centers, and the use of telemedicine. New models of supervision should be explored. In an ideal training program, once a fellow is deemed competent with a particular component of practice, they would be allowed to practice with indirect or no supervision.7Halpern S.D. Detsky A.S. Graded autonomy in medical education—managing things that go bump in the night.N Engl J Med. 2014; 370: 1086-1089Crossref PubMed Scopus (47) Google Scholar These decisions are governed by educational policy, faculty comfort, hospital regulations, billing requirements, immigration restrictions, and the physical clinic or endoscopy space available. Changes would require discussions with multiple stakeholders. Professional societies could serve as forums for sharing expertise and mentorship in both clinical and nonclinical domains. They may also convene working groups of interested educators, fellows, and program leadership at national meetings to envision what this future should look like and set an agenda for programs interested in adopting this change. Opportunities for advanced degrees in clinical research, which has traditionally been at the heart of many academic divisions, already exist in many programs. This pathway for advanced training could be a model for incorporating diverse pathways in the reimagined fellowship. A personalized third year will make our fellowship programs more marketable to applicants. Of the 22 trainees in attendance at this session who were surveyed, 9 responded that they would be much more likely to choose a program with specialized tracks (4 responded they would be a little more likely and only one said it would not influence their decision). Respondents indicated that they would pursue a specialized track to make themselves more marketable for an academic position, to potentially be more involved in their future institution’s administration, and because they are interested in a career with a broad impact on population health. The most popular tracks were leadership and specialized clinical training (Supplementary Figure 3). The most common concerns they listed regarding specialized tracks were the potential to be distracted from acquiring and fine tuning “core” GI skills, time commitments required, and limited faculty expertise to provide said training. A career that fits a person’s strengths and passions, allows for autonomy, and enables the person to engage in diverse efforts is most likely to promote vitality and decrease burnout, especially if that person is embedded in an institution that supports their interests and development.13Shah D.T. Williams V.N. Thorndyke L.E. et al.Restoring faculty vitality in academic medicine when burnout threatens.Acad Med. 2018; 93: 979-984Crossref PubMed Scopus (44) Google Scholar By building these skills and habits early in training, we may be able to enhance career satisfaction and retain talented physicians in academic medicine. Developing gastroenterologists with diverse skill sets will likely better meet the current and future needs of society. Traditional research and academic focused pathways have helped to develop physician-scientists who ensure the continued generation of new knowledge for the field. However, we also need physicians who will make sure that knowledge translates to excellent, evidence-based, equitable clinical care within well-led health care systems. This goal requires discrete nonclinical skill sets that are not part of the current standard training curriculum. Some of these current gaps and potential solutions have been highlighted in this review. In many ways, we are at a crossroads. Traditional fellowship training is siloed, with learning occurring in discrete blocks of predetermined periods of time that may or may not make sense for an individual trainee’s career. We should endeavor to provide fellows with the training opportunities that make the most sense for them: this is what fellows want! A reimagined fellowship could transform the experience of our fellows and improve their readiness for clinical practice, while ensuring they become competent physicians for life. Supplementary Figure 2Examples of specialized clinical training. IBD, inflammatory bowel disease.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplementary Figure 3Interest in specialized training tracks reported by trainees at the 2022 Education and Training CSS at Digestive Diseases Week.View Large Image Figure ViewerDownload Hi-res image Download (PPT)