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Issues related to subspecialty education: Weasel words in action

1999; Elsevier BV; Volume: 135; Issue: 6 Linguagem: Inglês

10.1016/s0022-3476(99)70083-1

1097-6833

J.A. Stockman,

Health Sciences Research and Education

In recent times, we have heard a lot about the way words are used: how words characterize and shape; how words mischaracterize and distort. When America was young, Teddy Roosevelt complained about politicians using what he called “weasel words.” Weasels, as most Americans of the time understood, liked to sneak into hen houses, latch onto eggs, and suck the yolks out of them, leaving empty shells. As Roosevelt saw it, words were to some politicians what eggs were to weasels, tempting qualifiers that sucked meaning out of them. There are more modern examples of weasel words. Take the case of a former presidential hopeful for the year 2000 who commented in a news piece that, as the American century nears its end, our politics are experiencing yet another infestation of such words.1Alexander L. Watch out for weasel words [editorial comment].The Wall Street Journal. January 21, 1999; 18: 18Google Scholar Lamar Alexander remarked, “Would not Roosevelt recognize George W. Bush’s phrase ‘compassionate conservatism’ or perhaps Al Gore’s term ‘practical idealism’ as empty shells?” In each of these instances, one word in a phrase sucks out the importance of the other, so that in the end there is little real meaning left. We too use weasel words in pediatrics, including words that we have created to address certain subspecialty issues. For example, while we recognize the worthiness of allowing some who have the talent to become productive investigators to enter subspecialty training early as a way of addressing just one of many serious research shortfalls, we do this with a process that we term the special alternative pathway . What is so special about a pathway that is simultaneously special but alternative, particularly when such phraseology in its real application attracts fewer than 0.2% of all those in residency training? The special alternative pathway is just one example of weasel words related to the way we train fellows. Or take what we do now about research training requirements as part of our eligibility criteria for board subcertification. In order to be eligible for subspecialty certification, our fellows must demonstrate a “meaningful accomplishment in research.” This is usually done by the provision of a first-authored research paper in a peer-reviewed journal deemed acceptable to the subspecialty board. Abstracts, case reports, book chapters, and review articles do not suffice unless the latter represent a systematic review such as a meta-analysis. Given the vagaries of the evaluative process, the problems related to what constitutes quality in this area and the low standards for assessing research competency, as well as the question of whether the certifying boards ought to be in the business of making such an assessment at all, cause one to wonder whether the phrase “meaningful accomplishment in research” as we now use it also exemplifies a grouping of weasel words, particularly if the goal we seek is to create a greater cadre of serious investigators. Certainly, our existing standards to determine what is meaningful research during fellowship training do not accomplish this. We might as well use other, albeit tongue-in-cheek, similarly ineffective but perhaps more entertaining ways (Table I) of evaluating the qualities of our subspecialty fellows. Table IPossible method of evaluating subspecialty traineesTable available in print only. Open table in a new tab Issues such as the appropriateness of the special alternative pathway or our current requirements for a meaningful accomplislunent in research are but two of many concerns related to how we train our subspecialty progeny. These issues are diverse (Table II). Table IITraining issues facing subspecialties1.How to attract high-quality researchers2.Defining requirements of trainingContentDuration3.Funding4.Workforce definitions Open table in a new tab Prominent among the concerns of our subspecialties is a decrease in the numbers of those who are interested in fellowship training. During a period (Fig 1) when the number of individuals completing pediatric residency has been at an all-time high, both the percentage and, recently, the actual number of those exiting residency who go on to subspecialty training have actually declined (Fig 2). Fig. 2Percentage of pediatric residents choosing pediatric subspecialty career pathways, 1986-1998. SS, Selected subspecialties.View Large Image Figure ViewerDownload (PPT)The call to primary care in the nineties has begun to affect our subspecialty workforce pipeline. This underscores the need to find ways to increase interest in subspecialty training, particularly on the part of those destined for academic careers. Most of the issues facing our specialties are too complex to address today. Fortunately, the Federation of Pediatric Organizations and the Task Force on the Future of Pediatric Education II have assumed the complex task of trying to analyze and, if possible, deal with these broad and diverse topics. But back to the subject of how we train fellows. The Pediatric Academic Societies’ meetings have in recent years been a rich forum for airing subspecialty training concerns. In his American Pediatric Society Presidential Address in 1994, Dr Abraham Rudolph commented on both our categorical residency training and our fellowship training.2Rudolph AM American Pediatric Society Presidential Address 1994: Reflections on research: A call to arms.Pediatr Res. 1994; 36: 687-691Crossref PubMed Scopus (5) Google Scholar Concerning the former, he noted that our postdoctoral educational system has become increasingly rigid and that, in most residency training programs, the experience is markedly uniform and increasingly under the thumb of the Residency Review Committee and our American Board of Pediatrics. Additionally, he observed that during pediatric residency training, there is little time to embark on research interests and little opportunity for expression of individuality. About fellowship training, he noted that all the subboards had instituted a research requirement for fellows, resulting in an extension of their training requirements to 3 years. The result of all this, he suggested, is that the “eager beavers” leaving medical school have become tired old men and women by the time they have finished their training. While one can question the latter conclusion, it is legitimate to ask whether we have indeed added too much rigidity to our subspecialty training requirements, whether the length of training is a deterrent to seek out such careers, and whether the current goal of subspecialty training—to prepare for a future in academia—is a realistic one. This latter goal, fellowship training as preparation for a career in academic medicine, is one that we set for ourselves in 1990 when the Federation of Pediatric Organizations established its position on fellowship training in a statement that has been widely published.3Federation of Pediatric Organizations Statement on Fellowship Training.Pediatrics. 1991; 87: 265PubMed Google Scholar This statement includes the following points. •The Federation underscores the concept that the “principal goal of fellowship training should be the development of future academic pediatricians.”•Graduates of pediatric fellowship programs should be proficient in clinical care, teaching, and a selected area of research. The Federation statement also included some general guidelines for fellowship training. It noted that: •Training should require that each fellow have a mutually agreed upon research mentor.•Applicants for fellowship training should be selected on the basis of their level of commitment to the attainment of adequate research training and to a career in academic pediatrics as a physician scientist. Are we accomplishing these stated goals? Perhaps not, judging by the declining numbers of trainees who are entering full-time subspecialty careers in academic departments. In recent years, we have seen a steady decline in interest in full-time, academic, subspecialty careers on the part of our subspecialty trainees. Prior to the 1990s, it was clear that, with the exception of neonatal-perinatal medicine, the significant majority of fellows sought and obtained academic faculty positions. The trend recently has begun to move the other way. As one example, based on data the American Board of Pediatrics has accumulated, only 44% of those being examined for certification in adolescent medicine (Fig 3, A ) had already accepted or intended to accept full-time academic positions in 1994. The percent declined to 36% in 1997. Similar changes over time have been observed for most of the other pediatric subspecialties (Fig 3, B-F ). Whether these trends represent a lack of interest in academic careers, a lack of job opportunities, or some effect of negative role modeling can be debated; but the result is still the same. Despite our subspecialty training aspirations, fewer and fewer are now opting for full-time careers in academic medicine. Internal Medicine, through its board, has also recognized the need to try to standardize fellowship training pathways and to increase its cohort of trained investigators who stay within academia. It now has a physician scientist training pathway as part of its fellowship requirements. There is also a defined requirement for the research training associated with this pathway, but it is recognized that the responsibility for assessing this lies with program directors rather than with the certifying board. The latter feels that simply requiring a “published paper” will cause some trainees to trivialize the quality of their research experience by choosing those types of projects that have immediate or short-term outcomes. Given the issues presented, a reasonable person might conclude that we should be rethinking how we train subspecialists. Again, the Pediatric Academic Societies’ meetings in recent years have been forums for such considerations. Dr Rudolph, also in his 1994 Presidential Address to the American Pediatric Society, remarked that we should exercise greater flexibility and allow for greater individual preference in our training programs by recognizing that some trainees have no interest in research careers, while others have a major commitment to research. He additionally stated a belief that the boards should not inject themselves into research issues but should adhere to what they do well, assessing clinical competency. Dr Ralph Feigin, in his 1998 American Pediatric Society Presidential Address,4Feigin RD American Pediatric Society Presidential Address 1998: What is the future for academic pediatrics?.Pediatr Res. 1998; 44: 958-963Crossref PubMed Scopus (11) Google Scholar commented that we now have three types of subspecialists: community subspecialists, clinician/educator subspecialists within academic departments, and basic or clinical research physician/scientist subspecialists within academic departments. Dr Feigin also suggested that each of these types of subspecialists may require different training, specifically formulated to meet their career goals. Dr Allan Walker has also presented his views on how subspecialists might be trained in a very well thought out manuscript that recently appeared in Pediatrics .5Walker WA. A subspecialist’s view of training and pediatric practice in the next millennium.Pediatrics. 1998; 102: 636-644Crossref PubMed Scopus (10) Google Scholar There is a common theme to the suggestions of Drs Rudolph, Feigin, and Walker. That theme includes greater flexibility and perhaps the possibility of tracking within subspecialty fellowships. While one can argue with the details, the message is straightforward. Is it not reasonable to pause to take time to reexamine what we are doing with the way we train fellows? Indeed, one of the goals of the Task Force on the Future of Pediatric Education II is such an examination. What are some of the possible ways that we could address these issues? Let me suggest to you six possibilities (Table III). Table IIIRecommendations for changes in subspecialty training1.For each subspecialty, define the time required for clinical competency (may vary by discipline; for some, 12-18 months; for others, longer).2.Define a core research curriculum that includes the following (18 months minimum):Research design/methodologyStatisticsApplication of various technologiesOutcomes design/population analysesManuscript preparation/grant preparationStart research project (clinical/bench) appropriate for career goal3.Accept the concept of centers of excellence for fellowship training.4.The American Board of Pediatrics to withdraw from evaluating individuals on the basis of research competency. This is the role of the program director in a center of excellence for those trainees who move beyond the clinical and core research requirements.5.Subspecialty certification based on successful completion of the clinical and core research requirements. Advanced research training for those anticipating career as physician/scientist (clinical or basic) on a hand-tailored basis in a center of excellence.6.Change the name special alternative pathway (SAP) . Encourage its use for selected individuals. Open table in a new tab As far as the clinical portion of fellowship training is concerned, clearly we must define and then require whatever period of time that is necessary to become expert in the clinical practice requirements of the subspecialty. Not all subspecialties are equal in this regard. For one subspecialty, this might be as little as a year. For others, cardiology, for example, the length of clinical training might need to be significantly longer. Once the clinical training is completed, all fellowships should have a reasonably standard curriculum, probably of 18 months’ duration, that deals with relevant research-related topics including study design and methodology, statistics, population analysis, outcomes data protocol, manuscript preparation, and participation in some type of research project. The latter need not be particularly complex but should be sufficiently rigorous to give the trainee a feel for what it is like to be engaged in research. None of this should be construed to represent a “meaningful accomplishment in research.” This core clinical and core research methodology training will likely take 3 years for most fellows. Obviously, some trainees will want more of a research challenge, but the core of fellowship training should be high-quality, patient-oriented clinical training and a reasonably uniform initial exposure to a research experience. That is about all we can expect of everyone. You might be thinking that this is pretty much what we are doing now. It is, but such a clearer articulation demonstrates the reality that a 3-year fellowship training period does not, nor perhaps can it be expected to, produce the idealistic outcome envisioned by the Federation of Pediatric Organizations, that is, a totally balanced individual capable of seeking a full-time academic career and doing well in that career. How then do we achieve the goal of producing highly qualified trainees who can assume faculty responsibilities as physician/scientists? Although there is no magic bullet for this challenge, there are some things that we can do initially. One is to accept the recommendations that have emanated from the Task Force on the Future of Pediatric Education II, specifically with regard to the concept of centers of excellence for subspecialty training. This means a reduction in the more than 700 different fellowship training programs that we now have to a significantly smaller number with the resources to properly train individuals, particularly as related to their research experiences. If this were to occur, certifying boards, sometimes viewed as distant, ethereal entities, could and should withdraw from trying to define research competency on an individual basis by allowing the centers of excellence, along with the residency review committee, to do this on a center-by-center basis, determining which has the resources and commitment to train fellows beyond the core requirements outlined previously. Individuals trained in such a rich intellectual environment will likely have a greater probability of electing to continue further research training if resources exist for this purpose. Those who do not take the additional research experience to become physician/scientists will still have been trained in a manner that prepares them for practice either in the community setting or within academia as clinician/educators. The assessment of research competency would occur where it belongs, in the hands of those program directors, albeit fewer in number, who are willing to accept the challenge of being responsible to mentor those who are truly committed to research while also training those who will practice without this interest. Subspecialty certification eligibility would be based only on the core 3-year training requirements, with no need for an assessment of “meaningful accomplishment in research.” Weasel words need not apply. What about the special alternative pathway? Currently, this pathway is intended to permit highly qualified individuals who have the interest and intelligence to enter a fellowship program early to do so. The process bypasses 1 year of general pediatric residency, a year that presumably is freed up for an extended research experience. The problems with the special alternative pathway are fairly obvious. Few seem to know about it. Most view this pathway as somewhat offbeat, a non-mainstream way of developing one’s career. Even the term itself, special alternative pathway , is abbreviated to SAP , a less than complimentary acronym. There must be more than 1% of residents who are qualified to enter this pathway. Even if just 10% of those going on to fellowship training did so via this pathway, that would be 60 individuals who might have an extra year available for subspecialty training, presumably in the laboratory. The trick is to find these folks early, to do so in a manner that does not stigmatize them, and to be certain that they can meet the rigors of an accelerated program committed to research. Once on their training way, let’s give them a wide berth and serious flexibility. In this regard, it is important to remember the first rule of Carolina pig farming: “You can’t make a hog grow by measuring it three times a day.” Last, let’s change the name, special alternative pathway , to something more acceptable and encourage its use where appropriate. Might not physician/scientist pathway be better? Special alternative pathway and meaningful accomplishment in research are terms that, as currently used, do represent weasel words. The words within each phrase suck the life, or meaning, out of what is intended, that is, to produce a larger number of well-trained investigators. In Dr Balistreri’s introduction to this speech, he referred to the training I had at the hands of someone who could be truly called a pediatric master, Frank Oski. Even now, when facing difficult problems, I continue to seek Frank’s advice by re-reading his writings. Given the magnitude of the difficulties we have just discussed, perhaps a remark Dr Oski made in one of his Yearbook of Pediatrics commentaries is most appropriate. In 1989, he wrote, “There is no problem that a good miracle cannot solve.” Dr Oski clearly did not use weasel words. Frank, assuming you are in heaven, you now have a direct link to the guy who can create miracles. Ask Him to send a few this way.