National Pediatrician-Scientist Collaborative Workgroup comment on new ACGME requirements’ impact on pediatric physician-scientists

Physician-scientists are an integral part of the larger medical community as they are uniquely suited to investigate pathology seen at the bedside in the laboratory, as well as more quickly translate new discoveries from the bench to patient care. For example, physician-scientists have led many important recent medical advancements, including the discovery of oncogenes, vaccine development, initial development of chemotherapy for pediatric leukemia, and leading the response to the recent COVID-19 pandemic. Unfortunately, in the last four decades the number of physician-scientists in the United States has declined significantly.^1,2,3,4 Although the cause of this decline is certainly multifactorial, some of the major drivers include increased length of training, negative effects of health care finances on research support, insufficient protected research time, and fewer physician-scientist mentors. Given the paramount importance of physician-scientists, it is in the best interest of ACGME, and society, to leverage some of the proposed changes to invest in the development of this vital group.

The proposed changes, which are highlighted in Table 1, offer a number of opportunities for developing physician-scientists in pediatrics. Among the most valuable is an increased focus on individualization of the curriculum. In the current proposal, this individualized approach includes an increased allotment of individualized learning time that will complement the trainee’s career aspirations. This approach can be well suited to the physician-scientist who requires interweaving clinical training with development of the skills and momentum to lead an investigative program, a process that may necessitate extended training time for research. The allotment of increased individualized time could enable many programs to provide an experience that mirrors the Integrated Research Pathway (IRP) as outlined by the American Board of Pediatrics (ABP); the allocation of time for these pathways and the proposed individualized curriculum changes are shown in Table 2. The IRP currently offers residents up to 11 months across their second and third years to perform research; the ARP removes a year of residency and adds an entire additional year of research in fellowship. The proposed changes to the standard residency program would provide approximately 20 weeks of individualized time that could be tailored to research. While this is under half the time offered by the current ABP research pathways, it would still allow residents to gain exposure to research and would provide time to begin to develop a research program during a period of research exposure.

Given the success and widespread usage of the IRP, the potential increase in individualized time during residency may provide a tremendous opportunity to introduce more residents to scholarship and investigation as a career without further modifying the curriculum, delaying graduation, or requiring additional approvals. Programs have successfully used both the IRP and ARP to prepare residents for research careers with programs of different sizes and perspectives often demonstrating unique preference for how they implement these pathways.^5,6 The practical implementation of research curricula has been previously published including descriptions of scholar programs at Baylor, Duke, and through the national Pediatrician Scientist Development Program (PSDP).^7,8,9,10 While these programs offer research training programs that may encompass multiple years, their curricular frameworks can provide inspiration for usage of individualized training time to support physician-scientist development. At the same time, the development of specific curricula will need to meet the requirements of institutions and individuals and hopefully will be tailored by each program. We anticipate significant future innovation in this educational space if the new guidelines are implemented.

The new guidelines present challenges in addition to opportunities for the training of the physician-scientist and intersect strongly with demands on time, resources, and mentorship that we have previously highlighted.^5,11 In exchange for the increased time for individualized training during residency, pediatric residents will have decreased required commitment to inpatient ward and ICU services. This change may have several important impacts. First, reductions in inpatient coverage are likely to have a negative economic impact, especially on freestanding children’s hospitals that receive reduced GME financial support compared to hospitals serving the full lifecycle. Reductions in resident coverage will also necessitate increases in mid-level and faculty coverage with associated financial and time-driven costs. These extra financial burdens might lead some institutions to no longer support pediatric residency training. The changes in medical team coverage that will be required to make up for the absence of residents may be too costly for some institutions. One potential outcome is that the resident coverage would be transferred to fellows and early-career faculty. As the fellow and faculty interval is a critical time for scholarship development, such a shift would also negatively impact physician-scientist development. Alternatively, some programs may reduce the numbers of residents by shifting some of these historically service-learning opportunities to other non-physician advanced practice providers. This shift would run the risk of reducing the critical mass of trainees, peers, and near-peers in the learning environment and could impede the development of traditional networks that emerge through these interactions and promote investigation and scholarship.

Research that “moves the needle” is often rooted in clinical context; thus, it is conceivable that shifts in the depth or range of clinical experiences may change the impact of training on how residents develop research curiosity and career-defining questions. Therefore, programs will need to be mindful of how they distribute clinical and individualized training time and rotations to create the necessary perspective for clinical care that drives research forward. Additionally, a decrease in focus in certain inpatient and procedural skills may necessitate incorporating those areas into the fellowship curriculum, which may reduce scholarly time at that critical interval. While the opportunity to individualize training may offset this for residents who clearly know their intended specialty, changes in the foundational training components may have adverse effects. Programs may try to address this risk with additional mentoring to facilitate earlier decisions about subspecialty training, but such approaches will likely still leave some residents underprepared for fellowships that they select in the later portions of residency. Finally, the shift in available coverage may serve as a disincentive for programs to support the ABP ARP or IRP as these pathways further reduce the time available for clinical service from residents. Whether the ABP will update these pathways based on the new ACGME requirements is not yet known, but a dedicated pathway for physician-scientist training is important to many physician-scientist trainees and is an essential component of the commitment of Pediatrics to physician-scientist careers. A lack of support for these pathways may see prospective pediatricians choose other specialties such as Internal Medicine that would then be even more accommodating for training physician-scientists. Further work to understand how programs anticipate responding to these changes is crucial to preventing any negative impact on the development of future pediatrician-scientists nationally.

A second critical impact is on the training environment. As initially modified in section II.B.1.c, faculty members with subspecialty board certification were no longer required for training in their specific areas and were instead proposed to be replaced with faculty members with experience in those subspecialty topics. After an initial evaluation period, this proposed change was removed and newly released revisions now place a strong emphasis on board-certified subspecialists (https://www.acgme.org/globalassets/pfassets/reviewandcomment/320_pediatrics_impact-07102023.pdf). We are enthusiastic that initial feedback has been well received and incorporated by ACGME on this issue. This issue is of critical importance as the educational environment for physician-scientists is well supported by board-certified subspecialty pediatricians, who by requirement have produced innovation and scholarship in their field during their fellowship training. While many pediatricians care for a wide range of pediatric illnesses, the training required for subspecialty certification requires dedicated research and scholarship training. While most pediatric subspecialists will not go on to careers with substantial dedicated research time, the knowledge and skills gained from specialty training better enable these faculty to engage with resident trainees around the core scholarly issues and guide scholarly development at the residency level. A common anecdote is that resident physicians become pediatric scientists because they encounter mentors who foster their interest in inquiry or that they develop the skills for inquiry that later impact their careers, such as the critical role played by pediatrician Dr. Mona Hanna-Attisha in the Flint water crisis. Reducing mentors with this training is likely to deprive residents of the opportunity to realize their interest in a scientific career pathway and may thereby diminish the number of pediatricians choosing to become physician-scientists, further exacerbating workforce shortages that are themselves a threat to balancing clinical care and scholarly work.¹² We are grateful that this aspect of the proposed changes has already been modified.

Finally, we would like to highlight that the preamble to the ACGME program requirements (#Int.B) does not provide any acknowledgment of scholarship, research, and investigation - despite this being a defining career aspect of many pediatricians. The preamble rightly notes that pediatricians are flexible and adaptable physicians, advocates, and self-directed life-long learners. The paragraph on life-long learning goes on to note that “pediatricians stay current with advanced and emerging technologies. They understand and collaboratively navigate the changing business aspects of medicine. Pediatricians utilize data management science to inform patient care, resulting in high-value patient-centered care, continuous quality improvement, and equitable and ethical service delivery.” As a group dedicated to the development of physician-scientists, we are dismayed and disappointed that scientific investigation and discovery were not highlighted as a form of life-long learning given that it is a fundamental aspect of the development of future knowledge in the field. In this paragraph, it is hard not to sense a shift away from preparing pediatricians as investigators, despite the widely shared view that all pediatricians, regardless of career focus, should be able to engage in investigation just as they do in education and advocacy. The goal of training as a pediatrician is to broadly and deeply impact the lives of children. While pediatric physician-scientists may not always directly care for children in the clinical setting, their impact, which is grounded in training as pediatricians, is immensely important to the wider global community and to the future of our children’s health.

In conclusion, we applaud the commitment to individualized training time for all residents and the initial responsiveness of the ACGME to feedback on these issues. We hope that this individualized time is not negatively offset by extra shiftwork or back-up coverage that will preclude the deep, longitudinal work required for scientific development. We encourage the ACGME to consider the downstream consequences in the academic training environment that may result and for ACGME and training institutions to remain committed to fostering pediatrician scholars as part of the training environment, and we appreciate that ACGME has deferred implementation of these new requirements and is continuing to revise them. We implore the ACGME to formally recognize scholarly investigation as central to training as well as to the identity of pediatricians and the unique needs of our patients. Finally, we look to come together with our colleagues to embrace the belief that pediatrics is the specialty that cares for the future and, in so doing, it should continue to develop those best practices of investigation and discovery that will optimally shape the future for the children and adults of today and tomorrow.