Milestone achievements in a national sample of pediatric emergency medicine fellows: impact of primary residency training

Abstract

Background: Pediatric emergency medicine (PEM) fellowships recruit trainees from both pediatric and emergency medicine (EM) residencies. The Accreditation Council for Graduate Medical Education (ACGME) defines separate training pathways for each. The 2015 PEM milestones reflect a combination of subcompetencies from the two residencies. This project aims to compare the milestone achievement of PEM fellows based on their primary residency training. We hypothesize that fellows trained in pediatrics achieve PEM milestones at different rates than EM-trained fellows in the ACGME domains of patient care, medical knowledge, systems-based practice, practice-based learning, professionalism, and interpersonal and communication skills. Methods: This is a multicenter, retrospective cohort study of fellows from a national sample of U.S. PEM fellowship programs. Basic demographic information and deidentified, biannual milestone scores for 23 competencies were collected for fellows training between 2015 and 2018. Subcompetencies are scored on a 5-point milestone scale. Descriptive and multivariable analyses for longitudinal data were performed to compare milestone assessments by primary residency training.Results: Complete data were obtained for 600 fellows; 95% (570) and 5% (30) completed pediatric and EM residency, respectively. In both year 1 and year 2 of fellowship, the mean milestone scores of EM-trained fellows were statistically higher than pediatrics-trained fellows across the majority of subcompetencies. By the final year of training, there were no statistically significant differences in milestone scores for any of the subcompetencies.Conclusions: Fellow milestone achievement between groups was not significantly different by graduation. However, fellows entering PEM training from an EM background attained higher scores on the milestones than fellows from a pediatric background in the first year of fellowship. How to cite this article: Kou M, Baghdassarian A, Rose JA, et al. Milestone achievements in a national sample of pediatric emergency medicine fellows: impact of primary residency training.

Guiding Fellows to Independent Practice

“…Unlike residency trainees, fellows are board-eligible physicians that have already completed a core training program, allowing them to practice independently in their primary specialty 1 . While 2 distinct paths to fellowship for PEM (via EM or pediatrics residencies) may result in trainees entering fellowship with differing skill sets, a prior study found that fellow milestone scores reach equivalence by the end of training regardless of type of core residency training 4 . The evidence available to guide PDs to allow incremental decreases in direct supervision and increased entrustment of fellows to practice independently, however, remains sparse.…”

What to know about 2.0: Revisions to the pediatric emergency medicine milestones

“…A summary of the subcompetency‐specific additions, deletions, and updates to individual milestones is provided in Tables 2–4. While training programs have variably interpreted PEM Milestones 1.0, there was a general tendency to rate early PEM fellows lower in shared subcompetencies than they were upon graduating residency and to interpret Level 5 as a graduating fellow, rather than aspirational 6,7 . As a result, the working group deliberately worded narrative anchors to align with the Dreyfus model, ensuring that Level 1 matched expectations for a PGY‐4 and that Level 5 remained aspirational.…”

“…While training programs have variably interpreted PEM Milestones 1.0, there was a general tendency to rate early PEM fellows lower in shared subcompetencies than they were upon graduating residency and to interpret Level 5 as a graduating fellow, rather than aspirational. 6,7 As a result, the working group deliberately worded narrative anchors to align with the Dreyfus model, ensuring that Level 1 matched expectations for a PGY-4 and that Level 5 remained aspirational. These anchors were further revised based on expected levels of performance suggested in the public comment period.…”

“…Educators also lamented difficulties in sharing assessment tools across programs and disciplines 1,5 . The PEM milestones have additionally been criticized for a lack of expected continuity transitioning from residency to fellowship 6–8 …”

“…1,5 The PEM milestones have additionally been criticized for a lack of expected continuity transitioning from residency to fellowship. [6][7][8] The ACGME's review process was followed by iterative stages of community engagement to refine specialty-specific milestones.…”