The Accreditation Council for Graduate Medical Education states that “residents should participate in scholarly activity.” In this issue of Pediatrics, Abramson et al1 provide current data indicating that most pediatric fellows do not conduct scholarly activity, author a publication, or submit a grant application during their fellowships. Yet involvement in scholarly activity is considered a requirement for certification by the American Board of Pediatrics (ABP),2 with a broad definition of how those requirements can be met. These findings confirm observations over several decades, providing an opportunity to address several crucial questions. (1) What are the goals of the requirement for scholarly activity? (2) Can “scholarly activity” be more broadly interpreted to meet public health and professional goals? (3) Are there implications for the duration of training programs?
The original goal of the requirement for performance of scholarly activity was preparation of subspecialists in pediatrics for success in academic medicine. Academic practice was by far the primary postfellowship activity of pediatric subspecialists nearly half a century ago, when the requirement was introduced.3 Concern that physician-scientists are an endangered species4 has only accelerated.5 The Physician-Scientist Workforce Working Group at the National Institutes of Health (NIH),6 which I cochaired, describes the complexity of the problem. The NIH is an important player but cannot address the issues alone. Abramson et al1 found that having an NIH-funded institutional training grant (T32) doubled the probability that fellows will publish, but most programs do not have T32 support or the requisite academic faculty to support such a program.
The National Academy of Medicine conducted a Workshop on the Learning Health Care System addressing multiple aspects of the failures of contemporary American medicine to improve the health of the public. One of the key issues identified7 was the need for clinician involvement in and leadership of learning health care systems. Most pediatric subspecialists are practicing in institutional settings in which they have almost unlimited opportunities to improve care and have a positive impact on public health. This kind of work is inherently systems based, collaborative, and meets the ABP definition of scholarly. Skillful, trained physicians need to reassert organizational leadership if the dominant role of insurers and nonclinicians in driving care is to be redirected. The impact of the pandemic of coronavirus disease has made dramatically and painfully evident that science and public health are insufficiently valued and trusted. Expertise and organizational leadership are essential if specialists are to have sufficient influence to counteract antivaxxers and believers in unproven therapies.
A recurrent theme in the responses to Abramson’s queries was the duration of training. This is an issue for several reasons, including the fact that clinically competent third-year fellows are oversupervised and underpaid for their clinical activities whereas they have protected time for research activities. This contributes to the unconscionable fact that the average age of a first-time NIH independent grant (R01) awardee is 43 years, which potentially discourages potential trainees from pursuing academic careers.
What are the Implications of Abramson’s Findings?
Are the goals being met? The obligation to invest 12 to 18 months into scholarly activity and produce a publication is honored more in the breach than in the fulfillment. This amount of time for most subspecialist fellowship programs to focus on scholarship is insufficient for success as a physician-scientist to be achieved, which is not the career path of most trainees. As a profession, we have neglected our obligation to train those who can resuscitate our failing health care system, and we are not providing trainees with the skills to lead the institutions in which they will spend their careers.
How is scholarly activity interpreted? Among the components generally accepted as composing scholarly activities are doing experiments, measuring outcomes, defining variables, critical data analysis, discovering new pathways, and inventing new technologies. Systemic change and leadership based on scientific expertise is also considered a scholarly activity. The current ABP definition permits an extremely broad set of activities.
Is the duration of training appropriate? An arbitrary duration of clinical training has been imposed because of our failure to develop competency-based assessments and our need for coverage of hospital clinical services. We are losing potentially excellent trainees who are unwilling to spend their adulthood in perpetual adolescence.
With their data, Abramson et al1 confirm previous observations that scholarly activity is not incorporated into subspecialty fellowship training with disturbing frequency, indicating that it is viewed as a suggestion rather than a requirement. Training program directors mention lack of mentors as a barrier, but recertification processes encourage quality and system improvement as appropriate subjects for all subspecialists. It is time for pediatric professional leaders to use the broad mandates provided by the ABP to prepare fellows for their eventual careers, enhance pediatric institutional leadership, and consider positioning fellows who have demonstrated clinical competence after 2 years to emerge as full-fledged members of the profession while they continue their journey of life-long learning.
Opinions expressed in these commentaries are those of the author 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/ 2020-013953.
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Competing Interests
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.
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