A critical question for all pediatric fellowship training programs is whether the clinical experiences and education provided prepare trainees for “life after fellowship.” One essential potential exposure gap for fellows in neonatal-perinatal medicine (NPM) is in delivery room resuscitation of extremely preterm infants. These deliveries are rare (∼1% of all deliveries), and numbers vary considerably between training sites. Accreditation Council for Graduate Medical Education (ACGME) program requirements for graduate medical education (GME) in NPM include the provision of patient care experiences that are necessary for fellows to acquire skill in delivery room stabilization and resuscitation of critically ill neonates.1
Graduated pediatric residents enter NPM fellowships with wide variation in previous neonatology exposure for both knowledge and procedures because of both decreased exposure and increased supervision. NPM fellowship program directors report perceived deficiencies in preparedness for incoming NPM fellows across multiple domains.2 This variation in preparedness leaves NPM program directors with a complicated problem to tackle: individualized educational training, some of which is at the mercy of available clinical experiences and luck of the draw. The ACGME educational milestones were developed to describe developmental progression through medical training and provide individualized feedback on progression toward competency. However, clear and consistent definitions of competency and proficiency, validated tools to assess them, and the definition of an effective learning environment are lacking in NPM. Additionally, educational research supports that active forms of learner-centric teaching are the most effective, but most formal educational experiences in GME are passive and teacher centric.3,4
In this issue of Pediatrics, Gray et al5 report the numbers of very low birth weight (VLBW) and extremely low birth weight (ELBW) delivery room resuscitations that occurred at institutions with ACGME-accredited NPM fellowship training programs in the Vermont Oxford Network database from 2012 to 2017. These numbers were used to estimate high-risk delivery room resuscitation exposure for NPM fellows by taking the average number of VLBW and ELBW deliveries over 3 years at all training sites divided by the number of matched fellows in each included NPM fellowship program. On the basis of the inclusion of 74 NPM fellowship programs that were able to provide data for all 6 years, using a median number of 5.8 fellows per program, the authors calculated that the mean number of potential VLBW and ELBW deliveries per fellow over a 3-year time frame ranged from 14 to 214 (median 61) and from 7 to 107 (median 27), respectively. On the basis of limited reports regarding the number of resuscitations and procedures required to meet a minimum level of competency, the authors determined that NPM fellow exposure to key high-risk delivery room behavioral and technical skills was below a threshold for proficiency in >80% of NPM fellows in this study.5–7
These results are sobering and raise questions about the structure and number of NPM fellowship training programs. First, should NPM fellowship programs consider a paradigm shift in the traditional fellowship structure? If the goal of every NPM fellowship program is to create proficient neonatologists, then flexibility in clinical versus research time should be considered to allow for additional clinical rotations or individualized, nonrotation-based clinical training. Additionally, the academic NPM community must seize the opportunity to determine what level of competency is required for independent practice.
Second, should the number of fellowship programs (or fellows) be condensed to ensure adequate clinical and procedural exposure? The number of ACGME-accredited fellowship programs continues to increase.8 Gray et al5 argue that careful consideration should be given to the continuation and expansion of NPM training programs given their findings. In this light, recognition of the importance of front-line clinicians (physician assistants and nurse practitioners) and their educational and procedural training needs and continuing education cannot be overlooked.
We suggest some additional “tough medicine” for NPM fellowship training programs.
1. Consideration should be given to restructuring fellowship position numbers to clinical volume. Careful tracking of ELBW and VLBW deliveries and invasive procedures for NPM fellows needs to occur as well as possible reevaluation of the geographical distribution of fellowship positions on the basis of that tracking.
2. The ACGME program requirements for GME in NPM state that an NPM fellowship program’s educational and clinical resources must be adequate to support the number of fellows appointed to the program. Questions for all NPM programs should be as follows: (1) How do we quantify this? (2) What numbers are needed for competency versus proficiency? And (3) Can high-fidelity simulation be a substitute for direct clinical experience?
3. Research priorities for multiinstitutional NPM education should focus on the creation of standardized assessment methods to determine performance criteria for clinical competency and readiness for independent practice.
4. Protected time for trained NPM faculty educators, with experience and expertise in simulation and interprofessional education, should be prioritized to support the needs of all health care team members, including faculty.
We submit that continued NPM fellowship accreditation should focus on delivery room volume and the likelihood of fellow exposure to necessary clinical experiences and procedures. Programs that seek to maintain accreditation should also be required to provide alternative environments to supplement clinical exposure, such as simulation laboratories for procedural and team training and training opportunities at affiliated clinical sites. Finally, NPM fellowship accreditation should also seek to ensure that appropriate booster and refresher training for faculty members is instituted so that faculty members, who likely also lack consistent resuscitative and procedural experience, are capable of educating NPM fellows using best practices.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3641.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr French is chair of Organization of Neonatal-Perinatal Medicine Training Program Directors (ONTPD) and a member of the Subboard for Neonatal-Perinatal Medicine of the American Board of Pediatrics. Dr Eichenwald is chair-elect of the Subboard for Neonatal-Perinatal Medicine of the American Board of Pediatrics.