Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process.

BACKGROUND AND OBJECTIVES: Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones. METHODS: We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones. RESULTS: The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%). CONCLUSIONS: Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

Level of Supervision for the Entrustable Professional Activities Common to General Pediatrics and the Subspecialties Decreases from Residency to Fellowship.

OBJECTIVES: To compare level of supervision (LOS) ratings of graduating pediatric residents with their assessments as fellows for the five Entrustable Professional Activities (EPAs) common to general pediatrics and the subspecialties and to determine if the difference between ratings from residency to fellowship is less for the QI and Practice Management EPAs, since the skills needed to perform these may be less context-dependent. METHODS: We compared ratings of graduating residents with their assessments as fellows using LOS data from two sequential EPA studies. RESULTS: There were 65 ratings from 41 residents at the first fellow assessment. At graduation, most residents needed little to no supervision for all EPAs with 94% (61/65) of ratings level four or five. In contrast, only 5/65 (8%) of the first fellow assessments were level four or five. The ratings difference for the QI and Practice Management EPAs was similar to the others. CONCLUSIONS: LOS ratings for the EPAs common to generalists and subspecialists reset as residents become fellows. There was no evidence that the QI and Practice Management EPAs are less context-dependent. This study provides additional validity evidence for using these LOS scales to assess trainees in pediatric residency and fellowship.

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.

Child Health Needs and the Pediatric Cardiology Workforce: 2020-2040.

This article evaluates the pediatric cardiology (PC) workforce and forecasts its future supply. Produced as part of a supplement in Pediatrics, this effort represents a collaboration among the American Board of Pediatrics Foundation, the University of North Carolina at Chapel Hill's Carolina Health Workforce Research Center, the Strategic Modeling and Analysis Ltd., and members of the pediatric subspecialty community. PC is a complex subspecialty including care from fetal life through adulthood and in practice settings that range from the outpatient clinic to procedural settings to the cardiac ICU. Complex subdisciplines include imaging, electrophysiology, heart failure, and interventional and critical care. Using American Board of Pediatrics data, US Census Bureau data, and data from the modeling project, projections were created to model the subspecialty workforce through 2040. Across all modeling scenarios considered, there is considerable projected growth in the supply of pediatric cardiologists by 2040. However, there is significant regional variation in the projected supply of trainees relative to demand in terms of local population growth, with evidence of a likely mismatch between areas surrounding training centers versus areas of greatest workforce need. In addition, this article highlights areas for future focus, including efforts to attract more residents to the subspecialty in general, particularly underrepresented minority members; increased support, more part-time career options, and improved academic career advancement for women in PC; and the development of better "real-time" workforce data to guide trainees and training programs in decisions regarding sub-subspecialty job availability.

Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future.

This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.

Child Health Needs and the Pediatric Critical Care Medicine Workforce: 2020-2040.

This article, focused on the current and future pediatric critical care medicine (PCCM) workforce, is part of a supplement in Pediatrics anticipating the future supply of the pediatric subspecialty workforce. It draws on information available in the literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the American Board of Pediatrics Foundation in collaboration with the Carolina Workforce Research Center at the University of North Carolina at Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling and Analysis Ltd. A brief history of the field of PCCM is provided, followed by an in-depth examination of the current PCCM workforce and a subsequent evaluation of workforce forecasts from 2020 to 2040. Under baseline conditions, the PCCM workforce is expected to increase by 105% during the forecasted period, more than any other pediatric subspecialty. Forecasts are modeled under a variety of multifactorial conditions meant to simulate the effects of changes to the supply of PCCM subspecialists, with only modest changes observed. Future PCCM workforce demand is unclear, although some suggest an oversupply may exist and that market forces may correct this. The findings generate important questions regarding the future state of the PCCM workforce and should be used to guide trainees considering a PCCM career, subspecialty leaders responsible for hosting training programs, staffing ICUs, and governing bodies that oversee training program accreditation and subspecialist certification.

Child Health Needs and the Pediatric Emergency Medicine Workforce: 2020-2040.

Approximately 30 million ill and injured children annually visit emergency departments (EDs) in the United States. Data suggest that patients seen in pediatric EDs by board-certified pediatric emergency medicine (PEM) physicians receive higher-quality care than those cared for by non-PEM physicians. These benefits, coupled with the continued growth in PEM since its inception in the early 1990s, have impacted child health broadly. This article is part of a Pediatrics supplement focused on predicting the future pediatric subspecialty workforce supply by drawing on the American Board of Pediatrics workforce data and a microsimulation model of the future pediatric subspecialty workforce. The article discusses the utilization of acute care services in EDs, reviews the current state of the PEM subspecialty workforce, and presents projected numbers of PEM subspecialists at the national, census region, and census division on the basis of this pediatric subspecialty workforce supply model through 2040. Implications of this model on education and training, clinical practice, policy, and future workforce research are discussed. Findings suggest that, if the current growth in the field of PEM continues on the basis of the increasing number and size of fellowship programs, even with a potential reduction in percentage of clinical time and attrition of senior physicians, the PEM workforce is anticipated to increase nationally. However, the maldistribution of PEM physicians is likely to be perpetuated with the highest concentration in New England and Mid-Atlantic regions and "PEM deserts" in less populated areas.

Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020-2040.

Pediatric hospital medicine (PHM) established a new model of care for hospitalized children in the United States nearly 3 decades ago. In that time, the field experienced rapid growth while distinguishing itself through contributions to medical education, quality improvement, clinical and health services research, patient safety, and health system leadership. Hospital systems have also invested in using in-house pediatricians to manage various inpatient care settings as patient acuity has accelerated. National PHM leaders advocated for board certification in 2014, and the first certification examination was administered by the American Board of Pediatrics in 2019. In this article, we describe the development of the subspecialty, including evolving definitions and responsibilities of pediatric hospitalists. Although PHM was not included in the model forecasting future pediatric subspecialties through 2040 in this supplement because of limited historical data, in this article, we consider the current and future states of the workforce in relation to children's health needs. Expected challenges include potential alterations to residency curriculum, changes in the number of fellowship positions, expanding professional roles, concerns related to job sustainability and burnout, and closures of pediatric inpatient units in community hospitals. We simultaneously forecast growing demand in the PHM workforce arising from the increasing prevalence of children with medical complexity and increasing comanagement of hospitalized children between pediatric hospitalists and other subspecialists. As such, our forecast incorporates a degree of uncertainty and points to the need for ongoing investments in future research to monitor and evaluate the size, scope, and needs of pediatric hospitalists and the PHM workforce.

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.