FELLOWSHIP ACCREDITATION IN PEDIATRIC OTOLARYNGOLOGY:

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FELLOWSHIP ACCREDITATION IN PEDIATRIC OTOLARYNGOLOGY:

A Review of the Issues

David E. Tunkel, MD

Johns Hopkins Outpatient Center, Room 6231

601 North Caroline Street

Baltimore, Maryland 21287-0910

dtunkel@jhmi.eduMargaret A. Kenna, MD

margaret.kenna@tch.harvard.eduEllis M. Arjmand, MD, PhD

Ellis.Arjmand@chp.edu

During the past several years there has been ongoing discussion about two key issues in pediatric otolaryngology: 1) certification of individual otolaryngologists as pediatric otolaryngologists, and 2) accreditation of pediatric otolaryngology fellowship programs. These issues, while closely linked, are not the same.

Certification is a process, similar to board certification in otolaryngology, where individuals are certified by some certifying body as having special or added qualifications to practice pediatric otolaryngology. This may involve training requirements (i.e., fellowship completion), review of case lists, and special qualifying tests in pediatric otolaryngology. This issue is being reviewed by another committee of ASPO and will not be addressed here.

Accreditation of fellowship programs is a process of review of the structure and content of a programs educational and clinical content, with formal accreditation of the program, not the individual fellows. There are a variety of issues that must be discussed when considering the accreditation of pediatric otolaryngology fellowships. This document is to provide a framework for discussion of these issues.

1. What are the advantages of fellowship accreditation?

a. It provides assurance and protection to the fellow candidates that theywill receive appropriate, well-rounded training the encompasses the full breadth of Ped Oto. This is the same reason why you would only want to attend an accredited residency program. The principal advantage is standardization of training to ensure that completion of any fellowship in pediatric otolaryngology provides expertise in some defined core of our subspecialty.

b. Such uniformity will help define pediatric otolaryngology as a subspecialty, and define the role of the pediatric otolaryngologist within pediatrics and otolaryngology.

c. Such fellowship accreditation is already performed in other pediatric surgical specialties (general pediatric surgery).

d. If certification of pediatric otolaryngologists occurs, and fellowship training is a requirement for certification, these fellowships should be standardized by accreditation.

2. What are the disadvantages of fellowship accreditation?

a. The accreditation process may be cumbersome or expensive to the programs.

b. The process of accreditation may reduce the number of fellowships, by eliminating programs that do not pass accreditation standards. This may be seen as an advantage or disadvantage. While eliminating sub-par fellowship programs ensures quality, some good fellowship programs may find the accreditation standards difficult to meet due to institutional difficulties not related to the training program.

c. Some fellowships may experience financial problems because accreditation of some types (ACGME) may preclude routine clinical billing by fellows, regardless of level of training.

d. The goal to standardize fellowships may eliminate unique features of given programs that are suited for a certain type of fellowship applicant.

3. Who would accredit the fellowship programs?

a. With the support and guidance from ASPO, the ACGME has already accredited a number of pediatric otolaryngology residency (fellowship) programs. These residencies have a defined structure with regard to clinical time, research experience, number of faculty, etc. Under ASPOs direction, the criteria for pediatric otolaryngology program approval were created in 1995. These criteria include a two-year fellowship, with a 6-month research block, as well as the need for a fellowship director and at least one other faculty member. (see www.acgme.org for detailslook under residency review committees for otolaryngology)

b. The American Society of Pediatric Otolaryngology (ASPO) or a Fellowship Committee within ASPO: This organization has neither certified or accredited in the past, and would need new tools to do so. In 1995 ASPO decided that they would rather have the ACGME do this accreditation, since they do it for nearly all other medical specialties. The concept of ASPO performing accreditation of fellowships that have been attended or taught by its own members may have its own set of problems. Should the ASPO membership decide to want fellowship accreditation, but for some reason not want the ACGME to do it, then ASPO would have to reverse the course it has taken for the last 7 years. ASPO or an ASPO committee would then need to create a curriculum and accreditation criteria, administered by some organization outside ASPO. In summary, ASPO already did all this with the ACGME, and they are really designed to do accreditation.

4. What would be considered in the accreditation process?

a. Duration of fellowship training. This indeed has its own controversies, as reasonable people have disagreed about the appropriate length of training for pediatric otolaryngology fellowship. Currently, approved fellowships are required to be 2 years long, based on ASPO direction submitted to the ACGME in 1995. Many have argued that this is excessive for those not needing or desiring research training. There is not agreement among fellowship directors on this issue. The ABO has stated that they do not prescribe how long a fellowship needs to be, but they have indicated that should the ACGME approve fellowships for one year or longer, they would qualify to sit for certification, if a certification process was available. Currently, this is not an issue for peds oto since we do not certify, and even if we did, the ACGME guidelines only accredit 2 year programs. But the ABO position leaves the door open for one year fellowships in any OTO subspecialty (otology/ neurotology, facial plastics, peds oto) to be adequate to sit for a certifying exam should the ACGME accredit such fellowships.

b. Exposure to research training---type and duration. The need for research training in pediatric otolaryngology can vary based on the career and employment goals of a given fellow, as well as on the background and prior training of these individuals.

c. University affiliation. This has been used as a criterion for accreditation of other subspecialties in otolaryngology. University affiliation often affords an academic atmosphere but we would need to investigate whether such affiliation is a crucial factor in maintaining fellowship standards.

d. Clinical experience---depth and variety. Most of us agree that pediatric otolaryngology fellowship training requires exposure to a wide variety of surgical procedures, diagnoses, and medical treatments that are usually seen only in a high volume tertiary pediatric facility.

e. Faculty---number of faculty members and training of such faculty. If fellowships are accredited and/or individuals are certified, must all fellowship faculty be certified or graduates of accredited fellowships?

5. How would accreditation of fellowships affect certification of individuals?

a. Certification process would likely require completion of an accredited pediatric otolaryngology fellowship. If certification of individuals as pediatric otolaryngologists does not occur, accreditation becomes a less important issue.

6. How would accreditation of fellowship programs affect the number of programs?

a. This process may reduce the number of fellowships, particularly if accreditation is linked to certification. This is particularly important now, as the number of fellowship applicants seems to be declining, and as the number of employment opportunities and perceived need for pediatric otolaryngologists increases.

7. How would accreditation of fellowship programs affect practicing pediatric otolaryngologists?

a. Accreditation of fellowships has the risk of at least temporarily creating a two-tiered population of pediatric otolaryngologists, those from accredited programs and those from other programs (or not fellowship trained). Again, this can be viewed as an advantage or disadvantage. Is it a quality control issue? We have valued members of our subspecialty who are not fellowship trained. Would completion of non-accredited fellowships cause us to not value these individuals who share the same passions we do? Should we be concerned that their training has not met certain criteria?

b. The number of trained pediatric otolaryngologists will decrease if fellowship programs decrease in number from accreditation.

Other subspecialties within otolaryngology have been addressing accreditation issues in a variety of ways. The facial plastic and reconstructive surgeons have over 40 one-year fellowships that are reviewed by a committee of AAFPRS. A standard curriculum has been established. This committee reviews case lists, instructor qualifications, and university affiliations. None of the programs are ACGME-approved, but the AAFPRS is initiating such a process. This may reflect the unique issues of facial plastic surgery with regard to general plastic surgery.

The head and neck fellowships are reviewed by the training council of the American Head and Neck Society, with review of programs and site visits. ACGME approval has not been sought.

Ten otology fellowships have been accredited by the residency review committee of the ACGME, using criteria established in 1995 (as has happened with four pediatric otolaryngology fellowships). There are a number of otology fellowship programs that are not ACGME-approved. The structure of the accredited 2-year fellowships is detailed in the ACGME website. Most significantly, completion of an ACGME-accredited otology/neurotology fellowship is listed as the standard pathway to qualify for the otology/neurotology subspecialty examination (this links accreditation with certfication). There is an alternate pathway proposed to sit for this test, available for a limited period (??) of time------ABO diplomate with at least seven years of active and sustained practice in otology/neurotology (>60% of practice).

CLOSING COMMENTS

Accreditation of fellowships in pediatric otolaryngology has both positive and negative points. The difficulties in standardizing our training process may reflect our difficulties in defining the content and boundaries of our subspecialty. The current ACGME accreditation process has not been ideal, both because of the financial issues of a residency program and the defined structure of the fellowship required for accreditation. Many programs without ACGME accreditation have continued to function and thrive, producing excellent fellowship-trained pediatric otolaryngologists. Any future efforts at accreditation of fellowships must address the unique positive attributes of each fellowship program as well as the differences in prior training and career goals seen in our fellows. Accreditation of these programs must define some minimum curriculum required for pediatric otolaryngology practice. All discussions of certification and accreditation should recognize our apparent workforce problems in pediatric otolaryngology as well as our need to maintain a level of competence and training beyond that received in otolaryngology residency. We must reconcile the need to attract and train increasing numbers of pediatric otolaryngologists while maintaining excellence in the training programs and the subspecialists who enter our field.