#470 - ABP Reverses Course on Two Year Neo Fellowship

Hello friends 👋

The American Board of Pediatrics has reversed course. After months of pushback from the neonatology community, the ABP has excluded neonatal-perinatal medicine from the two year fellowship waivers it is now granting to seven other pediatric subspecialties. Neonatology fellowship stays at three years. Ben is joined by Dr. Patrick Myers, past chair of ONTPD and fellowship director at Northwestern, and Dr. Brooke Vergales, ONTPD co-chair, to break down how this happened. They describe how program directors, division chiefs, and the AAP Section on Neonatal-Perinatal Medicine presented a unified position, why the ABP listened, and why both guests still consider this a pause rather than a settled outcome. The episode also covers what the reversal did not change: entrustable professional activities are still arriving over the next 18 months, and the scholarly activity requirement is still being dropped. ONTPD's response is a new committee to define what an excellent neonatologist must know at graduation.

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

Ben Courchia, MD (00:00.637)

Hello, everybody. Welcome back to The Incubator Podcast. We're back for a breaking episode about recent developments in the fellowship reform saga. I am joined in the studio by two returning guests. First, Dr. Patrick Myers, ONTPD (Organization of Neonatal-Perinatal Medicine Training Program Directors) past chair and fellowship director at Northwestern. Patrick, welcome back to the show.

Patrick Myers (00:26.779)

Thank you for having me again.

Ben Courchia, MD (00:28.327)

It's always a pleasure. You're a favorite of ours, so the more we can have you, the better. We are also joined today by your colleague, Dr. Brooke Vergales, who is the ONTPD co-chair, calling in from the New York area. Brooke, welcome to the podcast.

Brooke Vergales (00:48.918)

Thank you for having me.

Ben Courchia, MD (00:50.747)

Of course. We've talked about ONTPD in the past. For people who are just learning the acronym, it's the Organization of Neonatal-Perinatal Medicine Training Program Directors. You have both had a strong role and a strong voice in this conversation, so it makes sense that you're both here. I guess we should begin by discussing what has been evolving over these past two weeks. The highlight is that the American Board of Pediatrics (ABP) is rolling back its intention to move fellowship in neonatal-perinatal medicine from a three-year training program to a two-year training program. That is the big news, and there are some details we'll talk about more. But Brooke, as we were discussing off air, one of the good things is that it feels like our collective voices were heard throughout this process, at least. That's already quite gratifying and satisfying. What are your thoughts on that?

Brooke Vergales (02:01.655)

Yeah, I do want to recognize that the ABP did listen to us as a cohesive group. We've been working not only within ONTPD, but with our division heads and with the AAP (American Academy of Pediatrics) Section on Neonatal-Perinatal Medicine, to come up with a unified voice about our concerns about moving neonatology fellowship to two years, or giving select programs the option to move to two years. I do think they heard our concerns and recognized that maybe we need to do a little more work together, in partnership, to come up with a plan moving forward. So at least for the near future, neonatology will not be eligible to apply for waivers for two-year fellowship programs.

Ben Courchia, MD (02:55.825)

Very good point, and I'm glad you're highlighting this, because some specialties will be allowed to move to two years, specifically adolescent medicine, developmental-behavioral pediatrics, pediatric endocrinology, infectious diseases, nephrology, rheumatology, and pediatric emergency medicine. But not neonatology, and that's pretty much all we care about on this podcast right now. Patrick, did this come as a relief to you as well?

Patrick Myers (03:24.11)

Yes, with a big caveat. I think we did some really good advocacy, because we were really concerned about lowering the bar. It really felt that way to me. To be fair to the ABP, I don't think they felt that way at all. So part of this is figuring out how to partner with them well, to better articulate what is happening in our subspecialty and let the experts, our community of neonatologists and APNs (advanced practice nurses), talk about the best way to train fellows, and have them listen, because the prior plan wasn't going to work. I really viewed this as a pause. I would guess they're hoping we will come around, much like we're hoping they will come around. So I think there's going to be a lot more discussion in the future.

Ben Courchia, MD (04:22.309)

It does feel like a moratorium in a way, because things are still happening for these other specialties. For neonatology specifically, there are two changes still coming down the pike that are important to mention. The first is the institution of EPAs (entrustable professional activities), where a fellow or trainee will have to demonstrate their ability to do certain things, supervised by mentors and attendings who sign off to confirm that they have the competencies needed to meet the criteria for graduation. I'm currently training in hemodynamics in Canada myself, and I go through exactly that. I have to file these EPAs to show that I can do certain things. So that is still happening. What do you think about that? Is it something you're looking at with some reserve, or do you see it as an arena where we'll be able to structure things to get at that excellence that, Brooke, you were mentioning earlier?

Brooke Vergales (05:34.006)

I could take this first. I don't think we know a lot about the EPAs at this point. Over the next year and a half, which is really what we have to implement them, we as an organization of program directors are looking at best practices for implementing them and what they mean. We're really trying to come together, because I want to believe this will be a good form of evaluation for our fellows and trainees. But I still think information needs to be gathered from our group. That is our goal over the next 18 months: to get that data, look at best practices, understand what the EPAs mean for our graduating fellows, and learn what our graduating fellows think is currently missing from our programs. Where we are very strong as a community is that we want to work together. So I think that's going to be one of our big goals over the next 18 months within ONTPD.

Ben Courchia, MD (06:44.112)

Patrick, do you think there's an opportunity to structure these EPAs in a way that makes sense for where our field has arrived? One thing I'm thinking of: could there be an EPA for a fellow having a conversation with a family about end-of-life care? That's obviously critical, should be seen as a procedure, and would make perfect sense as an EPA. What are your thoughts?

Patrick Myers (07:06.692)

I actually think it's a great opportunity. It's a way to have us think deeply about how we assess and evaluate fellows, and to do it on a national level so there's some consistency and we can start measuring outcome metrics. It's also a way to make the assessments faculty give to fellows more meaningful. One thing I'm excited about is that it may allow us to take workplace-based assessments, much more frequent but tiny practical assessments, and build them into a much more robust way of looking at people, including things we historically haven't talked about much, like how you have conversations with families and how you deal with end-of-life care.

What's tricky is that there are two very distinct things happening that need to be wedded together. One is what the ABP will require for you to sit for your boards. In some ways, we just have to hit that metric, and it's not clear to us yet what those numbers will be. They've preset 10 EPAs already, and each will have to be assigned some level of entrustment. Take "manages a team," in a nutshell: you go from never having managed a team to managing a team without supervision, with many steps in between. We don't know what level of entrustment will be required. So part of it is what the ABP wants, and how we can collectively gather that data and get there. More important to us, and we spent an entire day and a half talking about this, is how we actually use these tools to innovate and provide the best experiences for our patients in the future.

Ben Courchia, MD (09:07.816)

For people who are not familiar with EPAs, some can be mandatory and some can be optional. Take "manages a team." To simplify, let's say it means you're able to outline the multidisciplinary plan of care for your patient that day. The ABP might say you need to do this a certain number of times to be checked off for that skill, and then you're good. Other EPAs are good to report but may not be required for graduation. As you mentioned, they may also let us structure interactions that already happened in the unit during training but were never really documented anywhere, and codify them a little better, instead of you walking into your program director's office and saying, "I did that with Jim the other day, he was there, he can vouch for that." Is there anything else people should know about EPAs, besides the administrative burden they might create? What else might they bring to the table in terms of structuring competencies that really make sense for our fellows?

Patrick Myers (10:29.824)

I think if we're careful about this, we can actually reduce the burden. Historically, you get an evaluation at the end of the rotation, and it's not particularly satisfying. As program directors know, you're twisting arms to get these things, and then they're not granular or actionable. We've just started to roll this out in my program, and I'm aiming for short, clear, and practical. My faculty have really bought in. In about a seven-and-a-half-week period, I've gotten slightly over a hundred EPA evaluations, because they take thirty seconds to two minutes to complete. It's not a ten-minute slog. And I'm starting to see patterns, like who's communicating well and who's doing well with procedures. It will take us some time to figure this out, and we've got some very good people and committees working on it. What we're trying to do is talk this through and get it working for all of us, so it's not a burden for the programs, the fellows, or the faculty, and it's actually useful.

Brooke Vergales (11:50.198)

I totally agree with Patrick. This could be a wonderful opportunity for fellows, because a lot of times we find out there are issues, but six or nine months later. What Patrick has done at Northwestern, getting a hundred-something evaluations in seven weeks, shows that if we can make this simple and quick, we may be able to help our fellows in real time and reduce the burden of trying to track down what the real issues are. So long term, I think this could be extremely beneficial to our fellows.

Ben Courchia, MD (12:29.417)

As a fellow myself, I feel like it's become part of my end-of-day routine. During the day, you note an interaction and think, "I could file an EPA for this one." Then at the end of the day, as you sign your notes or co-sign orders, you also file your EPAs, because, as Patrick said, it doesn't take long at all. It's a very well-structured process, and once you've done one or two, you can go through that little form very rapidly. So I think it can easily become part of the fellows' end-of-day routine and should integrate quite well.

The other thing we wanted to talk about is the other ABP announcement: the removal of the scholarly activity requirement for board eligibility. That has generated a lot of chatter, because it's currently an important component of training. How are you interpreting this news? Does it mean we've thrown quality and research out the window? Or will there still be room for that type of work in the future? What are your initial reactions? Patrick, I'll let you take this first.

Patrick Myers (13:49.723)

I think what the ABP said, and Brooke is better at this, so please fill in if I get it wrong, is essentially that a scholarly work product is no longer required at the end of fellowship, but we still have to provide curriculum that advances EPAs in other ways. Globally, the program director community and the section chief community disagree with this approach. But just like with EPAs, we actually view this as a real opportunity for innovation. Can we meet the ABP's metrics and do much better?

One idea we're working hard to think through is an area of concentration. One of the things that sets a neonatologist apart from other providers is the ability to dig deeply and critically and deal with the most complex problems. You often do that by developing a niche, be it hemodynamics, medical education, or basic science. So could we substitute the scholarship requirement with an area of concentration, broaden that, and set a national curriculum around it? Follow-up, hemodynamics, POCUS (point-of-care ultrasound), MedEd, research, neuro-NICU, advocacy, palliative care. There's easily a list of 10 to 15 things. What we're really asking is for our fellows to be excellent neonatologists and then also dig deep on one topic. So how do we do that? Brooke, sorry, I talked a while.

Brooke Vergales (15:43.278)

I completely agree. I think this is one of the most controversial things the ABP has done in the eyes of program directors. I'm in Patrick's camp on this, in that I also don't see it as a completely bad thing. We are one of the only boards in medicine that ever required scholarly activity and a scholarly work product. And I'm not sure we could say that, because of that, pediatrics is doing so much better research than any other field of medicine. I want to believe that. But the American Board of Pediatrics is focused on producing competent, good clinical neonatologists. Our job as training program directors is to give them something that sets them apart. And I agree with Patrick, this may give us a chance to innovate.

There still need to be physician-scientists, and I think there still will be. This allows people who want to be physician-scientists to get a lot of extra attention in that area. But there's also a good proportion of fellows who can very much contribute to neonatology without the pressure of having to write a manuscript. All of our fellows can be excellent. It's our job right now, and this is going to be our second big focus, to determine what training is required to be an excellent neonatologist. We as a community are really focused on that right now, and we're putting together a committee. How much clinical time and clinical exposure do you need, especially with decreasing neonatology requirements in residency? What is that going to look like? And on top of that, what does it look like to be an expert in something else, like hemodynamics or POCUS, as Patrick said? We need to come up with standards so that when you come out of fellowship, you can market yourself as an expert in that area. I think this gives us the opportunity to innovate. But I still think we need to encourage some form of scholarship; the scholarship EPA is still there. That's where we as program directors set expectations for what our fellows need to accomplish to keep contributing to the field of neonatology.

Ben Courchia, MD (18:28.606)

The worst-case scenario being that you create a poorly designed web-based module and say, "All right, done." How do we avoid that path of mediocrity and build something of substance that actually meets fellows where they are and allows them to grow in an area that was potentially untapped until now?

Patrick Myers (18:51.168)

It gets very easy to look at the ABP requirements. The easiest thing for us would have been to say yes, and a hundred and ten programs just check boxes. That takes an hour or two of my time, I'm done, and I never have to think about it again. Instead, what we said was, let's make ourselves better. So it's super painful, but also kind of exciting.

Brooke Vergales (19:20.109)

We have a lot of work to do within the organization to figure out what we want out of our fellows, and there's a lot of excitement surrounding that right now.

Ben Courchia, MD (19:26.634)

Because our fellows are entering a specialty that has really been transformed over the last twenty years. A few things come to mind for me. The patient population is drastically different; training in the mid-1990s versus today is a different world altogether. As you mentioned, Brooke, there's a level of sub-subspecialization where the NICU (neonatal intensive care unit) no longer feels like the end of the road. There are lots of opportunities beyond the NICU to learn about specific topics. The approach has also changed dramatically. Procedures used to be the big thing in neonatology, and thankfully we're doing fewer and fewer of them. But fellows still need to be ready for these low-frequency, high-intensity events.

The last piece, the way I think about it, is that fellows may not want to be active participants in the quality-driven work happening around them, but they still need to be good appraisers of it. You may not want to do bench research or clinical research, and that's fine. You may just want to take care of patients. But you should still be able to critically appraise a paper and understand whether the data applies to your patient population. That's not something we're born with; it's something we have to teach. The problem is that these are all so different. In both of your opinions, how do we rethink training to address all these aspects? Is that going to be possible? Will we get it right on the first try, or will we have to tinker?

Brooke Vergales (21:14.721)

I don't think we're going to get it right on the first try. I really don't. But that's the fun of all this: we're going to get to innovate as we go along. One important point is that the ACGME (Accreditation Council for Graduate Medical Education) still has separate requirements for neonatology fellowship, which have not changed as of now. The ACGME will not make any changes to its requirements until 2029 at the earliest. That's where a lot of this comes in, like requiring QI (quality improvement) experience. The ABP was never the one saying that; that was usually the ACGME. Our next step is to advocate with the ACGME about what we think needs to be in the program requirements they publish. They accredit the programs, which is very different from the ABP, which certifies the individual physicians. So we're very much hoping to work with the ACGME to make sure that, as you said, nobody goes into neonatology without understanding how to do QI work. No matter what practice setting you go into, you're going to be doing that work all the time for your patients. These are the kinds of things we'll have to decide as a group: what will be required to graduate from a neonatology fellowship.

Patrick Myers (22:41.168)

And how do you balance papers? Take the PDA (patent ductus arteriosus) literature: read forty years of it, and good luck to you. It takes a lot of thought and understanding of the literature, how and why it changes, and study design to tease that out. If we want to say we're graduating experts and aiming for excellence, that's something we just can't abandon or box-check.

Ben Courchia, MD (23:09.961)

Patrick and Brooke, you mentioned that you're creating this committee to start looking at this. Can you tell us a little about that endeavor? Is it specific to ONTPD, or does it include members of other organizations? What is the roadmap for this committee?

Brooke Vergales (23:31.509)

This was actually the big topic at our recent meeting at the NCE (AAP National Conference and Exhibition) this weekend. We are actively putting out a call for ONTPD members to join a committee to really dig into the baseline requirements of a neonatology fellowship. That doesn't mean programs won't need different things. There are different program settings and different acuity levels. So every program is still going to be...

Ben Courchia, MD (24:00.277)

A shared requirement.

Brooke Vergales (24:02.007)

Shared requirements. Part of what we're trying to do is also bring division heads onto that committee, along with people from private practice, because what do they want from a graduating fellow who's going to take a job in their setting? So we're working with those groups within neonatology as well, and we want them to be part of this and have a say in what they'll want when they hire graduating fellows.

Ben Courchia, MD (24:36.043)

Very cool. Very interesting. Brooke, Patrick, thank you so much for going over these updates and letting us know what ONTPD is working on. I think everybody will be very happy to hear that ONTPD's approach is not to stop here, but to keep exploring ways to make neonatal fellowship training better and produce excellent physicians. We'll keep a close eye on how things evolve and touch base with you then. Thank you both.

Brooke Vergales (25:07.949)

Thank you so much for having us today.

Patrick Myers (25:09.861)

Thank you. Really appreciate it.