#341 - Is Two Years Enough? Fellowship Directors Respond to the ABP’s Proposed Training Overhaul

Hello Friends 👋

The American Board of Pediatrics (ABP) recently announced a move toward competency-based subspecialty training that would shorten fellowships — including neonatology — from three years to two. The proposal has sent shockwaves through the training community. In this episode, Daphna sits down with three leaders from the Organization of Neonatal Perinatal Training Program Directors (ONTPD): Dr. Patrick Myers from Northwestern, Dr. Heather French from the Children's Hospital of Philadelphia, and Dr. Melissa Scala from Stanford. Together, they break down what competency-based medical education actually means in practice, why the math simply doesn't add up when applied to neonatology, and what this could mean for procedural training, scholarly activity, fellow well-being, and ultimately patient care. They also address the workforce concerns driving the ABP's proposal, share survey data from program directors across the country, and offer concrete alternative pathways forward. The message from the field is clear: the community wants to innovate — but they want a seat at the table first.

Link to episode on youtube: https://youtu.be/8ZarM_B-heM

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Short Bios:

Dr. Melissa Scala: Melissa Scala, MD, is a Clinical Professor of Pediatrics in the Division of Neonatology at Stanford Medicine, where she serves as the Program Director for the Neonatal-Perinatal Medicine Fellowship. Her clinical and research efforts focus on neurodevelopmental outcomes and the bonding process in the NICU. Dr. Scala’s work investigates how early interventions, such as skin-to-skin care and maternal speech, influence neonatal brain maturation and white matter microstructure. A graduate of Georgetown University School of Medicine, she is a board-certified neonatologist dedicated to improving developmental care and long-term outcomes for high-risk infants and their families.

Dr. Heather M. French: Heather M. French, MD, MSEd, is an attending neonatologist at Children’s Hospital of Philadelphia and a Professor of Clinical Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. She serves as the Program Director for the Neonatal-Perinatal Medicine Fellowship and is the Assistant Director of the Neonatal Education Simulation Training (NEST) Program. Dr. French’s academic work is centered on medical education, neonatal resuscitation, and simulation-based training. A graduate of the University of California, San Diego, and the University of Pennsylvania, she is board-certified in Neonatal-Perinatal Medicine.

Dr. Patrick J. Myers: Patrick J. Myers, MD, is an Associate Professor of Pediatrics at Northwestern University Feinberg School of Medicine, where he serves as the Program Director for the Neonatal-Perinatal Medicine Fellowship. His academic work is centered on medical education and the development of national curricula to support trainees during early career transitions. Dr. Myers is the Past-Chair of the Organization of Neonatal Program Directors (ONTPD) and a recipient of multiple faculty teaching awards. He completed his medical degree at Rush University followed by his residency and fellowship at the University of Chicago.

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The transcript of today's episode can be found below 👇

Daphna Yasova Barbeau (00:01.598) Good morning, everybody. I am so honored to have a very special group in the recording studio today. We are going to discuss the most recent press release by the ABP (American Board of Pediatrics) concerning moving to competency-based subspecialty training and shortening fellowships — potentially including neonatology — to two years from the standard three years.

There are certainly a lot of stakeholders in this discussion. Today we'll be speaking with members of the ONTPD, the Organization of Neonatal Perinatal Training Program Directors. I'm so honored to have in the studio Dr. Patrick Myers, Dr. Heather French, and Dr. Melissa Scala. Thank you all so much for being here today.

Heather French (00:57.692) Thanks for having us.

Daphna Yasova Barbeau (01:00.158) My pleasure. I'll have you each introduce your roles on the ONTPD and your stake in the current conversation. Dr. Myers, if you'll get us started.

Patrick Myers (01:16.025) Yeah, thank you for having us. I'm the neonatology program director at Northwestern, and I'm a past chair of ONTPD. Like most of this group, I've spent a lot of time thinking about medical education. I've sat on ACGME, ABP, and AMP spec committees and subcommittees. Glad to be here.

Daphna Yasova Barbeau (01:44.561) Dr. French?

Heather French (01:52.706) I'm Heather French, the fellowship program director at the Children's Hospital of Philadelphia. I'm also a former chair of ONTPD, and in December I just completed a seven-year term on the neonatology sub-board of the American Board of Pediatrics. Like Patrick, I've also sat on many AAP and ACGME committees.

I'll say that we are just representing our viewpoints as program directors here. We're not speaking for any of the organizations in which we have roles.

Daphna Yasova Barbeau (02:26.004) Thanks. And Dr. Scala?

Melissa Scala (02:28.812) Hi — sorry, I have a cold, so forgive me for this recording. I'm Melissa Scala, the current program director at Stanford University, Lucile Packard Children's Hospital, and I am the current co-chair of ONTPD. Interesting times to be a leader.

Daphna Yasova Barbeau (02:51.348) Well, what do they say? The only constant is change. But that's what we're here to talk about today. Dr. Scala, maybe you can help level-set for us — what does the term "competency-based training" actually mean? What does that look like, regardless of the length of a fellowship?

Melissa Scala (03:17.996) Yeah, so competency-based medical education (CBME) is really the idea that different people may progress differently through their professional development, and that we should be very targeted in the various domains where we're developing their skills — really drilling down on what they need to

be able to do to practice medicine. In its purest form, CBME would have a time-dynamic aspect to it, where some people might mature faster — either because of prior experience or because they're picking things up more quickly — while others might need more time. This model has been used in other

forums in medical education and was actually already set to be rolled out using EPAs (Entrustable Professional Activities) in 2028. These new announcements from the ABP, while they link them to CBME, are separate from that rollout, which was already occurring. So in some ways,

they are not entirely connected in my mind, even though I think the ABP sees them as linked. It's just something worth noting.

Daphna Yasova Barbeau (04:51.866) So as a hypothetical on the extremes — say a fellow has done some other postgraduate training and came from somewhere else. Could someone theoretically complete all those competencies in one year? Or if a fellow was really struggling, could it take four years, regardless of how fellowships are structured?

Melissa Scala (05:13.442) I mean, that's the construct in its purest form. But you can imagine it's very difficult to implement — the impact on scheduling alone is quite challenging. The ABP has not implemented that quite dynamic a time scale for us. But yes, in its purest form, that is how it would work.

Daphna Yasova Barbeau (05:42.846) Thank you. Dr. Myers, did you want to add

something?

Patrick Myers (05:48.517) Yeah. I think the other thing to consider here is that even in its purest form, time still matters. There's variability around the time needed. But what I think makes neonatology and other procedurally-based specialties a little unique is essentially the concept of dwell time and procedures. You do need a certain level of experience with things like ECMO (extracorporeal membrane oxygenation). Those cases don't pop up every day — you can't

generate more ECMO runs or more 22-weekers. They come when they come, and you need to be around to experience both the initial and multiple stages of progression. And then there are procedures. One of the more painful realities for program directors is making sure we have enough intubations and chest tube placements for fellows. By shortening training, you run the real risk of reducing competency around some of our most critical procedural skills, simply because there are fewer opportunities. And so some of us have discussed that if this really goes through, one way to maintain procedural competence might actually be to reduce the number of fellows — and that in itself is a whole other can of worms.

Patrick Myers (07:38.353) It's tricky. I do think the ABP feels that CBME and the two-year model are tightly linked. And I think that may be one of our major disagreements — we believe it will reduce competency, while they believe it won't change competency. Part of that disconnect is that they haven't granularly thought through the details, and the details really, really matter.

Part of it is also that we haven't had a real opportunity for a granular discussion about training innovation and what it means for our specific specialty. We'd very much like to have that conversation. We've asked. And currently, we haven't been invited to the table.

Daphna Yasova Barbeau (08:27.956) Well, you've jumped ahead into what the concerns are in the community about moving from three to two years — and for listeners, we will also discuss the potential benefits of moving to two years. But there are a number of concerns about shortening training. You mentioned some of them, Dr. Myers. I'll let everybody weigh in on some of the additional ones.

Daphna Yasova Barbeau (09:33.14) And I don't want to interrupt, but just for listeners who may not be intimately involved with resident education — there's been a shift where residents have fewer NICU rotations and fewer ICU rotations overall, unless they self-select into additional training. What are those requirements currently?

Heather French (09:05.282) I can jump in here. I think the biggest challenge we face as training program directors is that, given the continual decrease in ICU exposure during residency, our trainees are showing up on day one of fellowship with far less experience than they did decades ago. And that's not our trainees' fault — that's just the way residency has been restructured

over time by the ACGME. But I think it's very fair to say —

Heather French (10:00.0) Currently, the ACGME requires that trainees spend 12 weeks in an ICU setting: four weeks in the NICU, four weeks in the PICU, and the remaining four weeks at the program's discretion. There's also a requirement for four weeks in the newborn nursery. Within this new training paradigm put forth by the ACGME, there are up to 40 weeks of

individualized curriculum time. However, given program logistics and the need for appropriate staffing, that idea of a "choose your own adventure" individualized path during those 40 weeks is very difficult to implement. So it is quite possible that trainees arrive on their first day of fellowship having had only four to eight weeks of exposure

in a neonatal intensive care unit — 12 weeks of ICU care total. The challenge is that, as we all know as neonatologists, our subspecialty is uniquely complex. We have changing physiology across gestational ages — a 22-weeker's physiology is very different from a term baby's. We're managing congenital conditions, multiple forms of mechanical ventilation, nitric oxide, therapeutic hypothermia (TH), ECMO, transport, procedures, complex family conversations, multidisciplinary team leadership, and navigating complex ethical care situations. It's a lot to condense into a two-year period. Now,

the ABP model puts forth 18 educational blocks regardless of whether a program remains a two-year or three-year fellowship. If a program opted for two years — and most programs define an educational block as four weeks in length — with

Heather French (12:16.652) two to four weeks of vacation per year, you're left with minimal downtime to process and reflect. And if we think about adult learning theory and reflective practice, there is simply no time in a two-year compressed schedule for that. And to Patrick's point about dwell time — sometimes training really does come down to luck, whether or not a 22-weeker happens to be born on your shift or not.

The idea of becoming a master in all of those domains in such a condensed period of time feels incredibly far-fetched.

Daphna Yasova Barbeau (12:54.405) Dr. Scala.

Melissa Scala (13:01.12) We've done the math. I think in this situation, the devil really is in the details, because on the surface, if you don't think too hard about it, it seems reasonable — we can be flexible, we have CBME to ensure competency, it allows for people to

respond to their prior experience. But what happened in the week following this announcement is that the ONTPD leadership sat down — with computers, really — and tried to figure out how this actually plays out. What would it look like if we tried to implement this?

Because what they're asking for is an almost 50% increase in clinical time while simultaneously saying that we're not training people as well as we should. So we penciled it out. And what ends up happening is that if you really do what they've asked, you end up butting up against — or outright violating — ACGME duty hours. You're asking fellows to work at roughly double what is

currently recommended for ICU physicians. And it's not clear that simply making them run faster on the gerbil wheel — which is essentially what we're doing by throwing them into more and more clinical time — is actually the best way to teach them. Because as Heather said, they don't have any time to go home, think through a really hard case they had, read about it — because all of that independent

reading is not included in this model. And then come back and do it better. In addition, if you're really going to make people do this, they're going to burn out. When I told my fellows about these proposed changes at our retreat, they basically said, "Absolutely not — I wouldn't survive." As it is, they

Melissa Scala (15:20.408) already suffer from secondary trauma. In residency, they're not really exposed that much to death and dying — but they are in neonatology fellowship training. They're right there in it. And they felt that physically and emotionally, this was not a tenable position.

Daphna Yasova Barbeau (15:41.749) Yeah. Thank you for highlighting the concerns about well-being and whether we can actually process all that learning using adult learning theory. And something else I've heard that I think bears discussion — even from me, as someone who's almost entirely clinical — is the concern about how this might impact research

productivity, scholarly activity, and our intervention pipeline for the babies we care for in the future. What has been the discussion around that topic? Dr. French?

Heather French (16:30.702) So with the new ABP model, scholarly activity — which is currently a requirement for all fellows to submit to the ABP in order to sit for their subspecialty certification exam — is going away. There is no longer a scholarly requirement. There is an EPA (Entrustable Professional Activity) that touches on scholarship, and fellows still need to be deemed

ready for unsupervised independent practice in scholarly work, but there's no formal requirement for it. Those two things seem very incongruous. We really do worry about the removal of a scholarly activity requirement, because it is those trainees who develop research skills during fellowship who really discover a knack for it —

and it's those people who push our specialty forward. We worry about plateauing innovation. We worry about the continued need for progress in patient outcomes. The impact that eliminating the scholarly activity requirement could have on fellowship is quite problematic to me personally, and I think many program directors share that view.

There are certainly many fellows out there who don't have a strong interest in research, and that's okay — we understand there will always be people who just want to focus on the clinical work. But what we would suggest is that during fellowship, everyone should develop an area of concentration — whether that's in the research domain, or whether it's someone who decides they want to build expertise in ECMO, hemodynamics,

or neonatal follow-up. We believe that developing domain expertise remains critically important. That's one of the things the program director community would like to push for — not the entire elimination of scholarly activity, but rather a focus on an area of concentration. But again, that would be nearly impossible in a

Heather French (18:54.316) two-year compressed fellowship with almost no downtime to develop a refined skill set that is ready to be deployed as trainees move toward independent practice. The other challenge with how the ABP interprets these additional clinical blocks is that they've suggested a lot of

programmatic flexibility in what can count toward clinical training. They're not going to necessarily dictate how those additional clinical blocks are defined. However, that doesn't quite make sense to me — because if the stated reason for restructuring fellowship and increasing clinical time is that we're graduating trainees who aren't ready for independent practice,

then those trainees really need to be spending more time in the environment where they build the specific skill sets needed for their future careers. The idea that if trainees aren't ready for independent practice, we can address that by putting them in more MFM (maternal-fetal medicine) rotations or neonatal follow-up rotations — that is not achieving the goal the ABP says is driving this overhaul. So it's a little frustrating.

The other thing many program directors are grappling with is that a large number of fellows and trainees across the country are unionized, and such profound changes to the training pathway will have to go through collective bargaining. And if we were to say, based on CBME, that a fellow is not ready for graduation, the hoops we would have to jump through as program directors — working with unions to extend someone's training — would be enormous. I'm not sure the ABP has even thought about that, but there are over 40,000 trainees in the nation who are currently unionized. It's just a very tricky problem to implement.

Patrick Myers (21:09.497) I wanted to go back a little bit to areas of expertise and scholarship. I think one really important big-picture point for me as a program director is that I'm not only trying to graduate competent fellows — I'm trying to graduate people who can lead medical teams and be true experts. When you become a mature neonatologist, you must be the expert in your field. The buck ultimately stops with you.

You need to be the ultimate problem solver. The depth of knowledge needs to be profound. And I think it's distressing that we're removing the scholarly component, because what it really allows is depth — maybe you do bench research, or maybe you're an expert in medical education or communication, or hemodynamics,

or fetal consultation, or working with families. As a community, neonatology must be the leaders and experts in our field. And jettisoning the development of these critically needed skills — which not only move us forward but frankly just keep us at the same level — is deeply distressing to me.

Daphna Yasova Barbeau (22:34.389) You've all certainly made a strong argument against reducing fellowship from three years to two years. But Dr. Myers, maybe you can speak to the other side — what is driving the push to move to two years? What workforce or training gaps is the ABP hoping to address, and is there data to support those assumptions?

Patrick Myers (23:11.041) That is actually the question many of us have raised in direct conversations with the ABP. To be honest, what I'm hearing from them doesn't make a lot of logical sense to me. I think we're simply starting from very different baseline priorities. It really comes down to two things. One is

not having worked through the details subspecialty by subspecialty. I actually think there are some subspecialties where this may be great, and I'm fully supportive — if a community of subspecialists thinks this is their path forward, more power to them. But the critical piece is listening to each subspecialty to understand what they need.

I also think there's a deep background anxiety in the community — though the ABP hasn't explicitly said this — about workforce issues. But my personal belief is that workforce won't be fixed until there's pay equity. If you look at the hundreds of thousands of comments on Reddit, Discord, and group chats, it really comes down to the fact that US MDs do not choose pediatrics because we are grossly underpaid and overworked compared to other physicians. Whether it's two years or one year isn't going to change that. My counter-example: I have a pediatric fetal surgery fellow who will be 42 before she graduates — she's done surgery, research, more research, pediatric surgery, fetal surgery. If people are passionate about a specialty

and are appropriately compensated for their very hard work, they will get there. Shortening training to two years isn't going to help much. But to your broader question about what could be good about two years — what I'm hearing from the ABP is that they were deeply frustrated that programs weren't implementing CBME and felt they needed to really shake up the system. And I think their

Patrick Myers (25:33.391) perspective is that they've shaken the system. But what I think they've actually done is broken it. We will be less competent. I personally believe we're racing toward incompetence. And as medical educators — and one of the great things about the neonatology program director community is how connected we are — we had 150 comments about this within 30 seconds of it being announced at APPD. We want to innovate.

Daphna Yasova Barbeau (26:00.147) I believe it — and that meeting was just this past week, right? About a week to ten days ago.

Patrick Myers (26:05.657) Yeah. We are so eager to be innovative and creative. There are many ways we could approach this. This particular approach is not functional. Melissa or Heather, do you have anything to add or clarify?

Melissa Scala (26:28.429) I mean, I understand the perspective of people going through medical school today. They're leaving with massive debt — college tuition has gone way up, medical training is incredibly expensive. And we're trying to solve that problem in the wrong way. They're right —

they are looking at this debt and making rational career decisions, and they're not choosing pediatrics because they're trying to figure out how to survive economically. But the real fix is pay parity. In many countries, being a pediatrician is considered a difficult and respected career — and those pediatricians aren't paid less. That's in keeping with a national trend of undervaluing care for children: we don't pay teachers, we don't pay pediatricians. But to say we're going to shorten training and get you one year closer to that attending salary — which isn't even that attractive in pediatrics — while potentially compromising training is

Melissa Scala (27:51.223) really scary. I think we need to be very thoughtful here. I know everyone is well-meaning — I'm not trying to paint anyone as a villain. People are using the tools they have at hand to try to solve a real problem. But the message you're going to hear from us over and over again is that the answer is partnership —

open dialogue, compromise, brainstorming together. They've been frustrated that programs haven't been more innovative, but the reality is that all of our training paths have been dictated to us by the ACGME and the ABP, with no real conversation. That's what we truly need in order to move into the next century and do the best for our patients and our trainees.

Heather French (28:51.342) I'll just add that we simply need to get people into pediatrics. If we can't recruit people into pediatrics, no one's going to care whether subspecialty training is five years or six years — we can't even get people into the field. When I think about the University of Pennsylvania, not this past year but the prior year — from a class of about 160 students, only three

matched into pediatrics, even though they rotate through CHOP as medical students where there is so much innovation and exciting work happening. So if we can't recruit people into pediatrics in the first place, shortening subspecialty training is not going to solve our problem. We need more exposure to pediatrics in medical school. People will say that two-year fellowships work in adult medicine — and they do work there, partly because trainees have had so much

prolonged exposure to adult care throughout their entire medical education, and the ACGME hasn't reduced inpatient exposure for internal medicine residents the way it has for pediatrics residents. We are so outpatient-focused. So a two-year path might work in adult medicine, but it doesn't translate to pediatrics — because of our lack of pediatric exposure at the undergraduate medical education level,

the pay disparity, and the way exposure to inpatient versus outpatient pediatrics during training has fundamentally changed. There is no one-size-fits-all training path. And that is what we want to build with the ABP — but we feel, again, that we've been left out of that conversation.

Patrick Myers (30:35.749) I think Heather is exactly right. And part of it is that pediatrics has become complicated enough that the outpatient needs and the inpatient needs are genuinely different — and with the ACGME changes and likely these ABP changes, we're very focused on the outpatient side. And I think a lot of us are worried that if you want to care for

sick babies or children in the hospital, we aren't going to be able to train people the way our families and their kids deserve. I've wondered whether we might actually better serve the goal that every pediatrician shares — truly taking excellent care of children — by acknowledging that we've differentiated enough to need two distinct training paths: one toward inpatient pediatrics and one toward outpatient pediatrics.

And part of the challenge is that when you look at all the major governing bodies — the ACGME, the ABP, the AAP, the chairs of pediatrics — almost exclusively they represent outpatient pediatrics or outpatient subspecialties. So neonatology has suffered from a lack of voice at the table. I think

being genuinely creative and innovative here is critical — and it may mean ultimately advocating for separate inpatient and outpatient training tracks.

Daphna Yasova Barbeau (32:14.601) That brings me to my next question. What are the alternatives to ensure a steady workforce? I heard pay equity mentioned, but setting that aside and focusing just on education — are there other alternatives to training that could highlight what some of you have mentioned about individualizing a learning pathway?

I know we had an interview with Dr. Maksim and Rasmija about whether we should be shortening residency rather than fellowship. What do other alternatives look like? And your answer might be that nothing needs to change — but what are the options? Anyone can take this.

Melissa Scala (33:09.579) Sure. When I had conversations with folks at the ABP, I said: if you really want to talk about competency — which they keep coming back to — we have to look at the entire arc of training. And that means going all the way back to the beginning. All of these folks in adult medicine do exactly that — they get exposure from the very start and they get a lot of it. So it doesn't really make sense to focus only on the last

couple of years of training. You have to look at the arc. And what we're already dealing with is that training time has been taken away from us. I don't know how many months of NICU exposure you had during residency, Daphna, but I'd guess it was more than four weeks. We also had more clinical autonomy back when I was a resident — which was a number of years ago now.

Daphna Yasova Barbeau (33:55.881) Yeah, for sure.

Melissa Scala (34:05.647) And I think autonomy is another issue in training overall. So when you look at the arc, let's start with residency. We've convinced someone to go into pediatrics. And what we're currently doing is putting them through three years of pediatric residency, much of which is outpatient-focused. Many of the rotations they complete they will never use practically.

So we've asked the ABP for alternative pathways. Can we truncate to two years of pediatric residency, removing things like adolescent medicine? You may encounter adolescents as parents in the NICU, but you are not going to practice adolescent medicine.

Can we reduce the clinic-heavy components? Can we preserve the training they actually need versus requiring them to do things they will never use? So far, the response has been disappointing — there seems to be very little interest in this model, even though other disciplines pursue it, like pediatric neurology. But it makes the most rational sense: look at the full arc, identify what is actually needed, and build a pathway around those blocks.

I'm not sure why there's so much resistance. I worry it has to do with not wanting to lose board-certified pediatricians and the financial implications of that.

Melissa Scala (36:04.109) What we would propose is the ability to create creative pathways through residency, to not shorten the critical three-year neonatology fellowship, and to be allowed to thoughtfully determine what clinical training is needed during fellowship — and to develop these

areas of concentration, probably on a somewhat national level, with program directors collaborating on what those look like. I think that's truly the map for a well-trained neonatologist of the future.

Daphna Yasova Barbeau (36:47.483) I love that. And I wanted to highlight — you mentioned that ONTPD is a tight-knit group. You've already met a number of times to discuss this, and you've been getting feedback from program directors across the country in all different types of programs. What's the overall feedback from the group?

Melissa Scala (37:14.423) Not surprisingly, most people are against this — but it's not universal. About 80% of programs are opposed. There's a group that's unsure, and about 10% may be supportive. If you look at why they support it, it's often driven by recruitment concerns. Some also don't want to deal with the research component

and know that some trainees don't want to do it either. So that's a real motivator. We do have meetings scheduled with folks who support it, because I think it's critically important to hear from community members with differing opinions — if they have a great idea I haven't thought of, I welcome it. That said, when you look at the

survey we did right after this announcement, even though about 80% of people are against it, when you ask what they think they're actually going to have to do with their training pathways, you get a lot of answers saying they're either unsure or they think they'll end up with a mix of two-year and three-year programs.

When you dig into that, it's because they believe that the ABP's decision to offer flexibility — which essentially signals that two-year training is equivalent — will mean they can no longer fund a third year of training. They're very worried that hospitals or universities, particularly in the current funding environment, will say,

Daphna Yasova Barbeau (38:56.383) Hmm.

Melissa Scala (39:08.163) "We're not going to pay for it. You figure it out." And unfortunately, what this creates — and again, this is the devil in the details — is a strange caste system where wealthy institutions can support a third year and less wealthy institutions cannot. The downstream effects of this get

Melissa Scala (39:37.827) really complicated

and make for some very difficult decisions ahead.

Heather French (39:53.206) I can add that every division director is going to make their own choice, but I can say that my division director here at CHOP has stated that under no circumstances will he ever hire someone who completed a two-year fellowship. He does not believe that two years is sufficient time, given the current residency structure, to allow for the level of maturation a trainee

would need to independently practice in a very busy, highly acute level four center. There are just a lot of implications about this training path that really need to be thought through. And it really feels like we're not being taken into consideration. We are proposing a five-year path — just as they are proposing a five-year path — but we want a two-year residency and a three-year fellowship. It simply

does not make sense to us to truncate the terminal phase of training, which is where trainees most need time to mature their skills and develop expertise.

Patrick Myers (40:58.745) Yeah. I worry a lot about this two-tier system — two versus three years — where we're going to lose some very good doctors who choose a two-year program. Our patients really deserve those physicians in level four, high-acuity units. And we're going to lose some of our best people because they made a decision early in their career to go to a two-year program, and

then they're not going to be hired — or it will be much harder for them to be hired — unless they have a PhD or some other mitigating credential. I do think what we'd really like is a pause — time to actually think through the details — and then an invitation to partner on innovation. Our initial proposal is two plus three, but there are many ways to ensure competency

and to make sure we're graduating doctors who are truly ready to care for our kids. But to do that, you actually need to talk to the people doing the training — and that's not happening right now.

Daphna Yasova Barbeau (42:07.999) Well, I really appreciate your expertise and your thoughts on this matter. Just so listeners know, we will have more episodes coming out with additional stakeholders

to talk about what this looks like going forward. What I'm hearing from all of you right now is that what's really being requested of the ABP is a pause — a chance to regroup and truly build a consensus from the community. I want to highlight some ways people can make their voices heard. If you go to abp.org and search for "subspecialty fellowship updates," they do have webinars where people can weigh in. May 6th has already passed at the time of this recording.

There's one on May 13th at 6 p.m. Eastern. There's one on May 19th at 5 p.m. Eastern. And there's one on June 3rd at 1 p.m. Eastern. I also know that TCAN has a REDCap survey out for trainees and early-career neonatologists to make their voices heard — we'll be posting that on our social media and in the show notes

for this episode at the-incubator.org. Are there other ways people should be reaching out to stakeholders — whether they're in academic or private practice institutions?

Patrick Myers (43:40.175) There's a paper coming out very shortly that will give you a lot more detail, so you can really think through this carefully — it will be in the Journal of Perinatology, and we're hoping to have it out in the next couple of days. There is also a large task force of about 55 chairs, section heads, and senior program director leaders who are going to meet and try to chart a path forward. I'm hoping one outcome will be

a mechanism for the broader private practice, academic, and all types of neonatologists to connect with us. We'll communicate that through our channels as it develops. And please do advocate — though I'll be honest, the ABP listening sessions have been experienced by our program director community as largely one-sided.

There was one just yesterday, and they ignored every neonatology-specific question. So it was a little disappointing.

Daphna Yasova Barbeau (44:44.189) So what I'm hearing is: communicate through our community pathways, so we can bring a unified consensus to the broader pediatric community. Melissa, Heather, Patrick — thank you so much for everything you do for trainees and for the community, and thank you for joining us today.

Melissa Scala (45:04.601) Thanks for having us.

Patrick Myers (45:07.267) Yeah, thank you. And on a bigger note — really appreciate you and Ben's work on making our learners better.

Heather French (45:11.086) Thank you.

Daphna Yasova Barbeau (45:15.901) Right back at you.