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Are Graduating Fellows Ready to Launch into Safe and Effective Practice of Their Subspecialty?

October 21, 2021

The training of residents and fellows is focused on competency-based medical education—meaning advancement is based on skill-level and not the amount of time spent in training. As part of this framework, the concept of “entrustable professional activities” (EPAs) are used. EPAs reflect the important routine tasks expected for a pediatrician in practice that an individual should be entrusted to perform safely and effectively without supervision. Turner et al found that pediatric fellowship program directors do graduate fellows who still require some degree of supervision for certain EPAs, most commonly related to non-clinical tasks like quality-improvement or leadership. How does this relate to fellowship program director expectations for what their graduates still need after finishing their fellowship? Are they graduating their fellows recognizing that they expect they still need more skills based on the EPAs? Weiss et al (10.1542/peds.2021-050196) address these questions in a new study we are releasing this week.

The authors surveyed 802 fellowship program directors (FPDs), representing 15 pediatric subspecialties, of whom 82% responded. FPDs were asked to compare the minimum level of supervision required for graduation with the level they expected after graduation. For the 7 common EPAs across subspecialties, each demonstrated differences between the supervisory level of entrustment for graduation and the level expected for safe and effective practice. Fortunately, the least amount of difference was seen in clinical EPAs with consultations and handovers needing the least amount of attention post-graduation from a clinical standpoint. Non-clinical EPAs needed more supervision post-graduation, especially in quality improvement, management, leadership, and research scholarship.

So, are fellowship programs not doing their job? Should fellowships be longer to ensure EPAs are achieved so that additional supervision is not needed? We asked leaders in fellowship education, Drs. Laura Chiel and Debra Boyer, to comment on these questions in an accompanying commentary (10.1542/peds.2021-053258). They remind us of the importance of lifelong learning across the continuum and that EPAs should not be an endpoint with fellowship, but that the expected level of unsupervised competency will require ongoing learning post-fellowship as these fellows move into faculty positions. Drs. Chiel and Boyer suggest ways that fellows, FPDs, and the division chiefs can work together to put into place educational opportunities to ensure the FPD are met by faculty. Both this study and commentary provide some educational food for thought that is well worth digesting—so be a good fellow and link to both articles to learn more.

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