Structured Training Programs,Structured Training Programs,Certification & Re-Certification:Certification & Re-Certification:

Perspectives from OverseasPerspectives from OverseasDavid Ingbar, MDDavid Ingbar, MD

Director, Pulmonary, Allergy & Director, Pulmonary, Allergy & Critical Care Division,Critical Care Division,

University of MinnesotaUniversity of MinnesotaPresident-Elect, ATSPresident-Elect, ATS

U.S. Training SchemaU.S. Training Schema• College – 4 yearsCollege – 4 years• Medical School – 4 yearsMedical School – 4 years• Residency – 3 yearsResidency – 3 years• FellowshipFellowship

• Pulmonary only - 2-3 yearsPulmonary only - 2-3 years• Critical Care only - 2 yearsCritical Care only - 2 years• Pulmonary & Critical Care (combined) – Pulmonary & Critical Care (combined) –

3 years3 years• ““Real Doctor”Real Doctor”

Point of Confusion (?)Point of Confusion (?)

Medical LicenseMedical License

Is not the same asIs not the same as

Certification in a SpecialtyCertification in a Specialty

U.S. Medical LicensingU.S. Medical Licensing• State specific licensing requirements – State specific licensing requirements –

vary significantly state to statevary significantly state to state• Most require degree (MD, DO, etc) plus Most require degree (MD, DO, etc) plus

one year of residencyone year of residency• License does not restrict the type of License does not restrict the type of

practicepractice• Hospitals, Payors or Employers may Hospitals, Payors or Employers may

restrict the types of practicerestrict the types of practice• Renewal of license requires: $; CME; and Renewal of license requires: $; CME; and

“staying out of trouble”“staying out of trouble”

Medical Certification in the USMedical Certification in the US• Individuals become certified in specialty Individuals become certified in specialty

and/or subspecialty areas through Graduate and/or subspecialty areas through Graduate Medical Education (GME) and meeting Medical Education (GME) and meeting certification requirementscertification requirements

• Training programs are accredited for the Training programs are accredited for the quality of their trainingquality of their training

• If a training program is not accredited, then If a training program is not accredited, then graduates usually can’t be certified.graduates usually can’t be certified.

• Different organizations involved in Different organizations involved in certification of individuals and training certification of individuals and training programsprograms

AAMCAssoc American Medical Colleges

ABMSAmerican Board of Medical Specialties

ABIMABP

American Board of Internal MedicineAmerican Board of Pediatrics

ACGMEAccreditation Council for Graduate

Medical Education

AHAAmerican Hospital Assoc

AMAAmerican Medical Assoc

The (American) Accreditation Alphabet

ABMSABMSAmerican Board of Medical SubspecialtiesAmerican Board of Medical Subspecialties

• Medicine and Pediatrics each are single Boards, Medicine and Pediatrics each are single Boards, including many subspecialtiesincluding many subspecialties

• Surgery has separate Boards of:Surgery has separate Boards of:• General SurgeryGeneral Surgery• Thoracic (& CV) SurgeryThoracic (& CV) Surgery• Colon & Rectal SurgeryColon & Rectal Surgery• Orthopedic surgeryOrthopedic surgery• OtolaryngologyOtolaryngology

• Emergency Medicine recently developedEmergency Medicine recently developed• Sleep recently recognized as a specialtySleep recently recognized as a specialty

American Board of Medical SpecialtiesAmerican Board of Medical Specialties• Organization of 24 Organization of 24 ABMS ApprovedABMS Approved medical specialty medical specialty

boards.boards.• Mission of ABMS: maintain and improve the quality Mission of ABMS: maintain and improve the quality

of medical care via the of medical care via the Member BoardsMember Boards’ professional ’ professional and educational standards for the evaluation and and educational standards for the evaluation and certification of physician specialists. certification of physician specialists.

• Certification to assure public that a physician Certification to assure public that a physician specialist certified by a Member Board of the ABMS specialist certified by a Member Board of the ABMS successfully completed an approved successfully completed an approved educational educational programprogram and evaluation process, including a and evaluation process, including a specialty exam.specialty exam.

• Coordinate the activities of its Member BoardsCoordinate the activities of its Member Boards• Inform public, government, profession and its Inform public, government, profession and its

Members concerning issues involving specialization Members concerning issues involving specialization and certification in medicine. and certification in medicine.

Individual vs Program CertificationIndividual vs Program Certification

Individual CertificationIndividual Certification• Graduate from Graduate from

approved programapproved program• Meet requirements to Meet requirements to

sit for Board examsit for Board exam• Pass Board exam(s)Pass Board exam(s)• Ongoing Continuing Ongoing Continuing

Medical EducationMedical Education• Meet on-going Board Meet on-going Board

requirementsrequirements• Re-certify Re-certify

(Maintenance of (Maintenance of Certification)Certification)

Program CertificationProgram Certification• Intermittent review of Intermittent review of

training programs by training programs by ACGMEACGME

• Specify required:Specify required:• curricula; curricula; • training experience; training experience; • faculty compositionfaculty composition• researchresearch• Procedure Procedure

competenciescompetencies

ACGMEACGMEAccreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education

• Non-profit council established in 1981 to Non-profit council established in 1981 to evaluate and accredit medical residency evaluate and accredit medical residency training programstraining programs

• Member Organizations:Member Organizations:• American Board of Medical SpecialtiesAmerican Board of Medical Specialties• American Hospital AssnAmerican Hospital Assn• American Medical AssnAmerican Medical Assn• Association of American Medical CollegesAssociation of American Medical Colleges• Council of Medical Specialty Societies. Council of Medical Specialty Societies.

• 27 Residency Review Committees (RRCs) 27 Residency Review Committees (RRCs) set standards in individual areasset standards in individual areas

ACGME and the RRC for Internal ACGME and the RRC for Internal Medicine (RRC-IM)Medicine (RRC-IM)

Internal Medicine RRC sets standards Internal Medicine RRC sets standards for Internal Medicine residency and for Internal Medicine residency and most sub-specialties of internal most sub-specialties of internal medicinemedicine• Includes pulmonary & critical careIncludes pulmonary & critical care

Pediatrics RRC has similar functionPediatrics RRC has similar function Sleep and Allergy/Immunology each Sleep and Allergy/Immunology each

have their own RRCshave their own RRCs

What Does the RRC Do?What Does the RRC Do?

• Issue general and subspecialty specific Issue general and subspecialty specific standards – change every 5 yearsstandards – change every 5 years

• Specify training program requirementsSpecify training program requirements• Certify/Re-certify programs (3-5 years)Certify/Re-certify programs (3-5 years)• On-site investigation & review for program On-site investigation & review for program

certificationcertification• Review individual programs – can approve Review individual programs – can approve

fully, approve with citations, put on fully, approve with citations, put on probation or decertifyprobation or decertify

Pulmonary Training ProgramPulmonary Training ProgramSelected RRC-IM Requirements I.Selected RRC-IM Requirements I.

Program Director:Program Director: • Receives at least 25-50% salary supportReceives at least 25-50% salary support• Protected time (average > 20 hrs/wk); Protected time (average > 20 hrs/wk); • Certified with at least 5 yrs experience;Certified with at least 5 yrs experience;

Faculty:Faculty:• majority involved in scholarship with productivity; majority involved in scholarship with productivity; • > 2 key clinical faculty (+PD) devoting > 10 hrs/wk to > 2 key clinical faculty (+PD) devoting > 10 hrs/wk to

programprogram

Curriculum:Curriculum: • written goals & curriculum for each rotation; written goals & curriculum for each rotation; • defined supervision & responsibilities for each rotationdefined supervision & responsibilities for each rotation• structured educational lectures (> 5/month)structured educational lectures (> 5/month)• significant research component (most with publications)significant research component (most with publications)

Pulmonary Training ProgramPulmonary Training ProgramSelected RRC-IM Requirements II.Selected RRC-IM Requirements II.

Duty HoursDuty Hours • <80 hrs/wk; average 1/7 days off; <80 hrs/wk; average 1/7 days off; • not > 24 continuous hrs; > 10 hrs off between not > 24 continuous hrs; > 10 hrs off between

days;days;• On call not more than 1/3On call not more than 1/3

Assessments Assessments • regular evaluations of fellows & programregular evaluations of fellows & program• Annual written evaluationsAnnual written evaluations

Didactic EducationDidactic Education• Required core curriculum/ proceduresRequired core curriculum/ procedures• Clinical rotations > 5 hrs/wk beyond pt careClinical rotations > 5 hrs/wk beyond pt care• Biostats; epidemiology; administrationBiostats; epidemiology; administration• Ethics & responsible conduct of researchEthics & responsible conduct of research

Pulmonary Training ProgramsPulmonary Training ProgramsRRC-IM Clinical Time RequirementsRRC-IM Clinical Time Requirements

Pulmonary OnlyPulmonary Only • 24 months duration (or more)24 months duration (or more)• > 12 clinical months> 12 clinical months• At least 3m critical careAt least 3m critical care• At least 9m pulmonary (non-CC)At least 9m pulmonary (non-CC)Pulmonary/Critical Care CombinedPulmonary/Critical Care Combined• 36 months36 months• Minimum clinical times: 6m pulmonary; Minimum clinical times: 6m pulmonary;

6m critical care; 6m P/CC6m critical care; 6m P/CC

ACGME’s Core Competencies of ACGME’s Core Competencies of Clinical TrainingClinical Training

““Programs must define the specific Programs must define the specific knowledge, skills & attitudes required and knowledge, skills & attitudes required and provide educational experiences for their provide educational experiences for their fellows to demonstrate:”fellows to demonstrate:”

• Compassionate, appropriate, & effective Compassionate, appropriate, & effective medical caremedical care

• Medical knowledgeMedical knowledge• Practice-based learning & ImprovementPractice-based learning & Improvement• Interpersonal & communication skillsInterpersonal & communication skills• ProfessionalismProfessionalism• System-based practiceSystem-based practice

Common Citations of Subspecialty Common Citations of Subspecialty Programs by RRC-IMPrograms by RRC-IM

• All major dimensions of programs aren’t All major dimensions of programs aren’t structured educational experiencesstructured educational experiences

• Continuity clinic at least ½ day per weekContinuity clinic at least ½ day per week• Insure meaningful, supervised research Insure meaningful, supervised research

experience for each traineeexperience for each trainee• Monthly have at least 1 conference each: clinical; Monthly have at least 1 conference each: clinical;

basic science; research; core conf & jrnl clubbasic science; research; core conf & jrnl club• All full time faculty must do research & present All full time faculty must do research & present

scientific presentationsscientific presentations• Residents do annual confidential program eval.Residents do annual confidential program eval.• Resident feedback q 6 months & end of rotationsResident feedback q 6 months & end of rotations

Pulmonary RRC-IM IssuesPulmonary RRC-IM Issues• Should there be a standard curriculum or set of Should there be a standard curriculum or set of

competencies?competencies?• What are good outcome measures to assess the What are good outcome measures to assess the

quality of training? quality of training? • How to best implement competency-based How to best implement competency-based

assessment?assessment?• Training based on time, rather than experiences Training based on time, rather than experiences

or patient disease statesor patient disease states• Is more clinical time always better? How much is Is more clinical time always better? How much is

sufficient?sufficient?• Balance of clinical training and research time for Balance of clinical training and research time for

developing academic physician-scientistsdeveloping academic physician-scientists• Who is setting the standards? RRC-IM includes 1-Who is setting the standards? RRC-IM includes 1-

3 pulm/CC specialists out of ~ 30 people3 pulm/CC specialists out of ~ 30 people

Certification of IndividualsCertification of Individuals• Discipline-specific Boards set standards for Discipline-specific Boards set standards for

individual training & certificationindividual training & certification• Duration of trainingDuration of training• Content areas to be assessed by Board Content areas to be assessed by Board

examexam• Procedure requirements (program Procedure requirements (program

director sign-off)director sign-off)• Nature of Board exam – written; oral; Nature of Board exam – written; oral;

bothboth• Maintenance of certification standardsMaintenance of certification standards

American Board of Internal MedicineAmerican Board of Internal MedicinePersonal Disclaimer:Personal Disclaimer: on Pulmonary Subspecialty on Pulmonary Subspecialty

Board for 6 years & current SEP Co-ChairBoard for 6 years & current SEP Co-ChairABIM Mission:ABIM Mission: “enhance the quality of health care “enhance the quality of health care

by certifying internists and subspecialists who by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes demonstrate the knowledge, skills, and attitudes essential for excellent patient care.” essential for excellent patient care.”

Functions:Functions:• Sets individual training requirementsSets individual training requirements• Assesses individual professional credentialsAssesses individual professional credentials• Certification exams – General IM 1936; Pulmonary Certification exams – General IM 1936; Pulmonary

1941; CC 19871941; CC 1987• Determines policies re profession & specialtiesDetermines policies re profession & specialties• Interacts with other BoardsInteracts with other Boards• Recommends individuals for RRC serviceRecommends individuals for RRC service• ABIM Foundation to develop new initiativesABIM Foundation to develop new initiatives

ABIM Pulmonary Exam BlueprintABIM Pulmonary Exam Blueprint• Infections 13%Infections 13%• Critical care medicine:   Lung 9%;   Non-lung 4%Critical care medicine:   Lung 9%;   Non-lung 4%• Sleep:   Respiratory 8%  Non-respiratory 2%Sleep:   Respiratory 8%  Non-respiratory 2%• Neoplasms 9%Neoplasms 9%• Airway Obstruction: Asthma 7%, COPD 7%, Other Airway Obstruction: Asthma 7%, COPD 7%, Other

2%2%• Interstitial lung disease-related disorders 6%Interstitial lung disease-related disorders 6%• Occupational and environmental disorders 5%Occupational and environmental disorders 5%• Pleural diseases 5%Pleural diseases 5%• Quality/Safety/Complications 5%Quality/Safety/Complications 5%• Epidemiology/Ethics/Statistics 4%Epidemiology/Ethics/Statistics 4%• Physiology/Metabolism 4% Cell biology 3.5%Physiology/Metabolism 4% Cell biology 3.5%• Vascular diseases 2.5%Vascular diseases 2.5%• Congenital/Neuromuscular/Skeletal disorders 2%Congenital/Neuromuscular/Skeletal disorders 2%• Transplantation 2%Transplantation 2%

ABIM’s “Secure” Pulmonary ExamABIM’s “Secure” Pulmonary Exam

• Approx overall 80% pass rate for first time takersApprox overall 80% pass rate for first time takers• Each new question is tested “live” and Each new question is tested “live” and

performance is assessed before it is counted in performance is assessed before it is counted in individual’s scoreindividual’s score

• Statistical analysis of performance of each Statistical analysis of performance of each question – assess whether it discriminates high question – assess whether it discriminates high and low scorers on other questions and whether it and low scorers on other questions and whether it is appropriately difficultis appropriately difficult

• Cost per new question used = ~ $2,000Cost per new question used = ~ $2,000• Questions require regular review, as practice and Questions require regular review, as practice and

knowledge changeknowledge change• Recertification exam pass rates usually 85-90%Recertification exam pass rates usually 85-90%

Maintenance of CertificationMaintenance of Certification

• Certification used to be permanentCertification used to be permanent• Now time-limited = 10 yearsNow time-limited = 10 years• Goals:Goals:

• improve quality of careimprove quality of care• insure professional competencyinsure professional competency• foster continued learningfoster continued learning• promote quality improvementpromote quality improvement

• Complete series of self-examination modulesComplete series of self-examination modules• Pass a secure examinationPass a secure examination• Cost = ~ $1200 (not including review courses)Cost = ~ $1200 (not including review courses)• ? Recertify in base specialty (IM) – optional??? Recertify in base specialty (IM) – optional??

MOCMOCSelf Examination ModulesSelf Examination Modules

• Self-Evaluation of Medical KnowledgeSelf-Evaluation of Medical Knowledge• Open Book, take home, not time-limitedOpen Book, take home, not time-limited• Medical Knowledge modulesMedical Knowledge modules

• ABIM ABIM OROR professional societies develop professional societies develop• May link to educational materialMay link to educational material

• Recent Advances Knowledge modulesRecent Advances Knowledge modules• Clinical Skills – PE & patient Clinical Skills – PE & patient

communicationcommunication• Self-Evaluation of Practice PerformanceSelf-Evaluation of Practice Performance

MOC: MOC: Evaluation of Practice PerformanceEvaluation of Practice Performance

Must do at least one of these (new requirement)Must do at least one of these (new requirement)3 Components3 Components• Demonstrate one uses quality measurement in Demonstrate one uses quality measurement in

practice; practice; • Select a relevant aim for improvement that is Select a relevant aim for improvement that is

based on measurement; and redesign one or based on measurement; and redesign one or more practice processes to improve that more practice processes to improve that measurement; measurement;

• Repeat relevant measurement to determine if the Repeat relevant measurement to determine if the change resulted in an improvement, and report change resulted in an improvement, and report your findings to the ABIM. your findings to the ABIM.

Practice Performance ModulesPractice Performance Modules• ABIM Practice Improvement Modules (PIM)ABIM Practice Improvement Modules (PIM)

• Chart abstraction and fill out web based formChart abstraction and fill out web based form• http://www.abim.org/moc/sempbpi.shtmhttp://www.abim.org/moc/sempbpi.shtm• Asthma module currently existsAsthma module currently exists

• ABIM Survey Modules (Peer, Patient, and Practice ABIM Survey Modules (Peer, Patient, and Practice Inventory) Inventory) • Survey 25 patients; 10 peers & self evaluationSurvey 25 patients; 10 peers & self evaluation• Communication module (CHAPS)Communication module (CHAPS)• Consultation module – in developmentConsultation module – in development

• Self-directed quality measurement and Self-directed quality measurement and improvement (create your own; needs approval)improvement (create your own; needs approval)• Uses data collected by others – health systemsUses data collected by others – health systems

Issues for ABIMIssues for ABIM• In transition from organization expert in In transition from organization expert in

insuring training and knowledge of physicians insuring training and knowledge of physicians TOTO

• Goal of increasing quality of patient care and Goal of increasing quality of patient care and promoting physician QIpromoting physician QI

• Balance needs for general internal medicine Balance needs for general internal medicine and subspecialtiesand subspecialties

• Currently looking at redesign of IM training to Currently looking at redesign of IM training to make it more popularmake it more popular

• Emergency Medicine split off as separate BoardEmergency Medicine split off as separate Board• ? Future of hospitalists in ABIM??? Future of hospitalists in ABIM??

Two Relevant Case StudiesTwo Relevant Case StudiesThe Good, The Bad or The Ugly?The Good, The Bad or The Ugly?

• Critical Care MedicineCritical Care Medicine• Sleep MedicineSleep Medicine

Critical Care in the USCritical Care in the US

• Accounts for ~ 20-25% of all hospital costsAccounts for ~ 20-25% of all hospital costs• Approx 1 of 3 ICU patients is cared for by a Approx 1 of 3 ICU patients is cared for by a

critical care specialistcritical care specialist• 90% of US critical care specialists are based in 90% of US critical care specialists are based in

Internal medicineInternal medicine• 85% of US critical care specialists are combined 85% of US critical care specialists are combined

Pulmonary & Critical Care trainedPulmonary & Critical Care trained• Joint Society & govt studies predict increasing Joint Society & govt studies predict increasing

and major shortfall in critical care physiciansand major shortfall in critical care physicians• Shortage of ICU nurses, respiratory therapists Shortage of ICU nurses, respiratory therapists

alsoalso

Critical Care as a SpecialtyCritical Care as a Specialty• As of mid 1980’s: Critical Care programs and As of mid 1980’s: Critical Care programs and

individuals are separately accredited by American individuals are separately accredited by American Boards of:Boards of:• Internal MedicineInternal Medicine• SurgerySurgery• AnesthesiologyAnesthesiology

• Should there be one homogeneous CC training Should there be one homogeneous CC training pathway and a single set of competencies?pathway and a single set of competencies?

• Should CC be a primary specialty, coming straight Should CC be a primary specialty, coming straight out of medical school? (like Emergency Medicineout of medical school? (like Emergency Medicine

• Should hospitalists be trained in critical care Should hospitalists be trained in critical care “Lite”?“Lite”?

• ? Role of Emergency Medicine physicians?? Role of Emergency Medicine physicians?

Sleep Medicine – Recent StatusSleep Medicine – Recent Status• Growing clinical & research interest in fieldGrowing clinical & research interest in field• Very high reimbursement for interpreting sleep Very high reimbursement for interpreting sleep

studiesstudies• Proliferation of sleep labs of variable qualityProliferation of sleep labs of variable quality• High prevalence of Sleep Apnea & other diseasesHigh prevalence of Sleep Apnea & other diseases• Field includes pediatric, neurologic, psychiatric & Field includes pediatric, neurologic, psychiatric &

psychologic componentspsychologic components• Most pulmonologists not trained comprehensively Most pulmonologists not trained comprehensively

in sleep medicinein sleep medicine• In US, great majority of clinical care provided by In US, great majority of clinical care provided by

pulmonologistspulmonologists• ““Rogue” (non-ABMS approved) group = ABSM Rogue” (non-ABMS approved) group = ABSM

offered a certification exam for many yearsoffered a certification exam for many years

Sleep Medicine – Present StatusSleep Medicine – Present Status• ATS defined recommended “basal” sleep ATS defined recommended “basal” sleep

competencies for all pulmonary traineescompetencies for all pulmonary trainees• ABIM Pulmonary Board now tests sleep ABIM Pulmonary Board now tests sleep

knowledge much more aggressivelyknowledge much more aggressively• ABMS recognized sleep as a specialtyABMS recognized sleep as a specialty• ABIM (with Neurology, Psychiatry & ABIM (with Neurology, Psychiatry &

Pediatrics) is developing a single certifying Pediatrics) is developing a single certifying exam in sleep to replace ABSM examexam in sleep to replace ABSM exam

• ACGME created a sleep RRC to certify ACGME created a sleep RRC to certify sleep fellowship programssleep fellowship programs

Sleep Medicine – The ProblemSleep Medicine – The Problem• Sleep certification required by increasing Sleep certification required by increasing

number of insurors/payors to reimburse number of insurors/payors to reimburse study interpretation &/or pt carestudy interpretation &/or pt care

• Certification now will require additional Certification now will require additional one year of dedicated training beyond one year of dedicated training beyond Pulmonary; Pulm/CC; or Internal MedicinePulmonary; Pulm/CC; or Internal Medicine

• ? Impact on attractiveness of Pulmonary ? Impact on attractiveness of Pulmonary professionprofession

• ? Impact on research time and academic ? Impact on research time and academic careers of pulmonary traineescareers of pulmonary trainees

• What happens when the high monetary What happens when the high monetary reimbursement goes away?reimbursement goes away?

ABIM – Old WorldABIM – Old World• Subspecialties (require 2 – 3 years each)Subspecialties (require 2 – 3 years each)

• Cardiology; Pulmonary; Hematology; Oncology; Cardiology; Pulmonary; Hematology; Oncology; GI; Nephrology; Rheumatology; Infectious GI; Nephrology; Rheumatology; Infectious DiseaseDisease

• Added Qualifications (require additional 1 Added Qualifications (require additional 1 year)year)• Critical CareCritical Care• GeriatricsGeriatrics• Electrophysiology; Invasive Cardiology;Electrophysiology; Invasive Cardiology;• Sports MedicineSports Medicine• Transplant HepatologyTransplant Hepatology

• Sleep – not includedSleep – not included

ABIM – New WorldABIM – New WorldProblems:Problems:• Increasing subspecialization & fragmentation of Internal Increasing subspecialization & fragmentation of Internal

MedicineMedicine• Increasing training times = less appealingIncreasing training times = less appealingAltered Structure:Altered Structure:• Subspecialties: traditional ones PLUSSubspecialties: traditional ones PLUS• Sub(sub)specialties with required parent:Sub(sub)specialties with required parent:

• Interventional Cardiology; ElectrophysiologyInterventional Cardiology; Electrophysiology• Transplant Hepatology Transplant Hepatology

• Subspecialties with “variant” pathways:Subspecialties with “variant” pathways:• Sleep medicine (only 1 year)Sleep medicine (only 1 year)• Critical Care (3 pathways)Critical Care (3 pathways)• Geriatrics (1 year training)Geriatrics (1 year training)• Adolescent MedicineAdolescent Medicine

ConclusionsConclusions• Rapid increase in required structures & Rapid increase in required structures &

documentation related to trainingdocumentation related to training• Much slower growth in development of outcomes Much slower growth in development of outcomes

assessment tools and ways to assess specific assessment tools and ways to assess specific training experiencetraining experience

• Setting standards for Training & Accreditation tends Setting standards for Training & Accreditation tends to be province of large multispecialty groupsto be province of large multispecialty groups

• Control and standard setting tend to be removed Control and standard setting tend to be removed from most knowledgeable individuals on the front from most knowledgeable individuals on the front lineslines

• Real risk: increasing clinical training times will Real risk: increasing clinical training times will damage the pipeline of academic MD scientistsdamage the pipeline of academic MD scientists

• Training mixed with Politics = DangerTraining mixed with Politics = Danger• Professional societies need to aggressively seek Professional societies need to aggressively seek

roles in determining proper training and roles in determining proper training and certification policiescertification policies

QuestionsQuestions• If learning is life-long, when is it sufficient If learning is life-long, when is it sufficient

for graduation or certification purposes?for graduation or certification purposes?• Who should decide and how?Who should decide and how?• Is long term performance of trainees Is long term performance of trainees

determined by the individual or their determined by the individual or their training process?training process?

• Does one size fit all?Does one size fit all?• Should we have different program training Should we have different program training

requirements for individuals who anticipate requirements for individuals who anticipate different career pathways?different career pathways?