Minimum Supervision Levels Required by Program Directors for Pediatric Pulmonary Fellow Graduation

Analysis of fellowship program director opinions of entrustable professional activities in adolescent medicine fellowship

OBJECTIVES

This study aimed to explore the minimum entrustable professional activity (EPA) supervision levels at which pediatric fellowship program directors (FPDs) would be willing to graduate fellows and the levels deemed necessary for safe and effective practice for each of the common pediatric subspecialty and the four adolescent medicine-specific EPAs.

METHODS

This cross-sectional study utilized survey data from pediatric FPDs in 2017. FPDs indicated the minimum level of supervision (LOS) for fellows at graduation and for safe and effective practice.

RESULTS

82 percent (23/28) of adolescent medicine FPDs completed the survey. For each EPA, there were differences (p<0.05) between LOS expected for graduation and for safe and effective practice. There was also variability in the level at which FPDs would graduate fellows.

CONCLUSIONS

This study summarizes pediatric FPD opinions regarding the minimum levels of supervision required for fellows at the time of graduation as well as the levels deemed necessary for safe and effective practice. The difference between the minimum LOS at which FPDs would graduate a fellow and that deemed appropriate for safe and effective practice, along with variability in minimum LOS for graduation, highlight the need for clearer standards for fellowship graduation as well as more structured early career support for ongoing learning. These data highlight variability in FPD opinion regarding such expectations and both the need to better define desired training outcomes and potential need for post-graduation supervision in clinical practice.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.

Exploring Factors for Implementation of EPAs in Pediatric Subspecialty Fellowships: A Qualitative Study of Program Directors

OBJECTIVE

To understand fellowship program directors' (FPDs) perspectives on facilitators and barriers to using entrustable professional activities (EPAs) in pediatric subspecialty training.

METHODS

We performed a qualitative study of FPDs, balancing subspecialty, program size, geographic region and current uses of EPAs. A study coordinator conducted 1-on-1 interviews using a semistructured approach to explore EPA use or nonuse and factors supporting or preventing their use. Investigators independently coded transcribed interviews using an inductive approach and the constant comparative method. Group discussion informed code structure development and refinement. Iterative data collection and analysis continued until theoretical sufficiency was achieved, yielding a thematic analysis.

RESULTS

Twenty-eight FPDs representing 11 pediatric subspecialties were interviewed, of whom 16 (57%) reported current EPA use. Five major themes emerged: (1) facilitators including the intuitive nature and simple wording of EPAs; (2) barriers such as workload burden and lack of a regulatory requirement; (2) variable knowledge and training surrounding EPAs, leading to differing levels of understanding; (3) limited current use of EPAs, even among self-reported users; and (4) complementary nature of EPAs and milestones. FPDs acknowledged the differing strengths of both EPAs and milestones but sought additional knowledge about the value added by EPAs for assessing trainees, including the impact on outcomes.

CONCLUSIONS

Identified themes can inform effective and meaningful EPA implementation strategies: Supporting and educating FPDs, ongoing assessment of the value of EPAs in training, and practical integration with current workflow. Generating additional data and engaging stakeholders is critical for successful implementation for the pediatric subspecialties.

Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors

Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.

Faculty Decision Making in Ad Hoc Entrustment of Pediatric Critical Care Fellows: A National Case-Based Survey

Phenomenon: Ad hoc entrustment decisions reflect a clinical supervisor's estimation of the amount of supervision a trainee needs to successfully complete a task in the moment. These decisions have important consequences for patient safety, trainee learning, and preparation for independent practice. Determinants of these decisions have previously been described but have not been well described for acute care contexts such as critical care and emergency medicine. The ad hoc entrustment of trainees caring for vulnerable patient populations is a high-stakes decision that may differ from other contexts. Critically ill patients and children are vulnerable patient populations, making the ad hoc entrustment of a pediatric critical care medicine (PCCM) fellow a particularly high-stakes decision. This study sought to characterize how ad hoc entrustment decisions are made for PCCM fellows through faculty ratings of vignettes. The authors investigated how acuity, relationship, training level, and task interact to influence ad hoc entrustment decisions. Approach: A survey containing 16 vignettes that varied by four traits (acuity, relationship, training level, and task) was distributed to U.S. faculty of pediatric critical care fellowships in 2020. Respondents determined an entrustment level for each case and provided demographic data. Entrustment ratings were dichotomized by "high entrustment" versus "low entrustment" (direct supervision or observation only). The authors used logistic regression to evaluate the individual and interactive effects of the four traits on dichotomized entrustment ratings. Findings: One hundred seventy-eight respondents from 30 institutions completed the survey (44% institutional response rate). Acuity, relationship, and task all significantly influenced the entrustment level selected but did not interact. Faculty most frequently selected "direct supervision" as the entrustment level for vignettes, including for 24% of vignettes describing fellows in their final year of training. Faculty rated the majority of vignettes (61%) as "low entrustment." There was no relationship between faculty or institutional demographics and the entrustment level selected. Insights: As has been found in summative entrustment for pediatrics, internal medicine, and surgery trainees, PCCM fellows often rated at or below the "direct supervision" level of ad hoc entrustment. This may relate to declining opportunities to practice procedures, a culture of low trust propensity among the specialty, and/or variation in interpretation of entrustment scales.

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

BACKGROUND

Entrustable 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.

OBJECTIVES

We 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).

METHODS

In 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.

RESULTS

One-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).

CONCLUSIONS

We 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.

Pediatric Emergency Medicine Fellowship Program Directors' Viewpoint: Minimum Levels of Entrustment for Graduating Fellows and Practicing Physicians to Perform the Subspecialty's Professional Activities

OBJECTIVES

Entrustable Professional Activities (EPAs) are essential tasks physicians perform within their professions. Entrustment levels that pediatric emergency medicine (PEM) fellowship program directors (FPDs) expect graduating fellows to achieve for PEM-specific and common pediatric subspecialty EPAs remain unreported. This study aims to determine minimum entrustment levels FPDs require fellows to achieve to graduate from fellowship and to compare FPD expectations for fellows versus practicing PEM physicians.

METHODS

Secondary analysis of PEM-specific data from a national multispecialty cross-sectional survey of pediatric subspecialty FPDs. For 6 PEM-specific and 7 common pediatric subspecialty EPAs, PEM FPDs indicated (1) minimum entrustment levels fellows should achieve by training completion, (2) whether they would allow a fellow to graduate below these minimum levels, and (3) minimum levels for safe and effective practice by PEM physicians. Minimum levels were defined as the level that more than 80% of FPDs would not drop below.

RESULTS

Sixty of 77 PEM FPDs (78%) completed the survey. Most respondents did not require fellows to achieve the highest level (level 5-no supervision) by graduation for any PEM-specific EPAs. The median level FPDs expected for practicing PEM physicians was 5 (trusted to perform without supervision) for EPAs 1 and 4 and level 4 (indirect supervision for complex cases) for the remaining PEM-specific EPAs. Minimum levels expected by FPDs for common subspecialty pediatric EPAs were lower for both groups.

CONCLUSIONS

Most PEM FPDs indicated that they would graduate fellows before their achievement of the highest entrustment level for all EPAs. Most also indicated that they do not expect practicing PEM physicians to perform all EPAs without supervision. These findings indicate need for stakeholders to evaluate current structure and outcomes of PEM fellowship programs and for institutions and organizations to ensure adequate support in time and resources for ongoing learning for practicing PEM physicians.