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Ann Allergy Asthma Immunol 111 (2013) 313e315

Perspective

The changing face of allergy/immunology fellowship programsHeidi Zafra, MD; and Asriani Chiu, MDDivision of Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin

A R T I C L E I N F O

Article history:Received for publication July 15, 2013.Received in revised form September 1, 2013.Accepted for publication September 5, 2013.

Reprints: Heidi Zafra, MD, Division of Allergy anCollege of Wisconsin, 9000 W Wisconsin Ave, SE-mail: hzafra@mcw.edu.Disclosures: Authors have nothing to disclose.

1081-1206/13/$36.00 - see front matter � 2013 Ahttp://dx.doi.org/10.1016/j.anai.2013.09.006

Introduction That individualized system for fellowship program selection for

Fellowship training in allergy/immunology (A/I) has evolvedthrough the decades. Up until a few years ago, the applicationprocess was much simpler, with just a submission of a completedapplication form and letter of interest and that all-importantinterview. Since then, the requirements and documentationnecessary to start and successfully complete an A/I fellowship havestockpiled. Are these changes really molding fellows to be betterclinicians, researchers, and clinician-educators, or is this justa more laborious way of documenting their training because themedical environment has been increasingly susceptible to litigiousinvestigation, and because of demands made by the public, theInstitute of Medicine, and the federal government? The changeshave been made across the board for the different specialties andsubspecialties in medicine, and it has been particularly challengingto keep up with accreditation.

In the last 5 to 10 years, some of the changes have included theapplication process, the level of supervision and necessary docu-mentation needed for evaluation of the fellows, and advances intechnology and the process of adult learning.

The Application Process

In the past, each program had its own application process. Therewas no standard or set time for applications or interviews. Appli-cants to A/I fellowship programs were able to focus on their owninterests, whether they were clinical care, research, the program’sreputation, and/or location. After the interview, an offer would bemade, and the applicant would have a few days to decide. In certaincircumstances, the applicant would be waiting to hear from otherprograms. The training programs also may have had to go “downtheir list” if an applicant was waiting to hear from another programor if an applicant accepted a position and then called back to ask torescind the acceptance to accept another offer. From eitherperspective, it was not an ideal situation.

d Clinical Immunology, Medicaluite 440, Milwaukee, WI 53226;

merican College of Allergy, Asthma &

the most part is nonexistent today. In 2006, A/I fellowship programdirectors (PDs) started discussions on whether to join the NationalResidency Matching Program (NRMP), which they thought mightalleviate some of the disadvantages of the old system. According totheNRMPwebsite, the reason to participate in thematching programis that it allows “applicants and programs to consider all their optionsand to select their most desired position(s) or individual(s) in a safe,confidential setting.” Furthermore, the “NRMP establishes a uniformschedule for applicants and institutions to make a selection withoutpressure.”1 In light of these resources and advantages, after muchdiscussion, PDs ultimately decided to participate in the NRMP.However, the disadvantage is that neither the program nor thecandidate is assured that they will matchwith their first choice, or atworst end up with a match that is not satisfactory to either theapplicant or the program. These riskswere believed to bepreferred tothe problems that occurred in the old system.

December 2007 was the first time that internal medicine and pedi-atric residents or graduated physicians applied through the ElectronicResidency Application System to fellowship programs in the UnitedStates andCanada forpositions that started in July2009. From last year’smatch,we know that the applicants apply to amean of 20 programs forUSmedical graduates and 32 programs for international medical grad-uates. The programs receive amean of 40 applications fromUSmedicalgraduates and 24 applications from international medical graduates.5

On average, the training program’s have 1 to 2 positions per year.Since the initial match, A/I programs have nowgone through the

NRMP cycle 5 times. This past year, the start date for the applicationprocess also changed. Applications are now downloaded on July 1for positions starting 12 months later, compared with previouslymatching the applicants 18 months before the fellowship start.Having a later match date allowed A/I to be more synchronizedwith the internal medicine subspecialty match and gave residentsmore time to decide whether an A/I fellowship is right for them.The pediatric subspecialty match also is contemplating this change.

The A/I Curriculum

In the past, whether a fellowwas successful in completing his orher training depended on the PD’s assessment of the fellow’s ability

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H. Zafra and A. Chiu / Ann Allergy Asthma Immunol 111 (2013) 313e315314

to function as an independent allergist. Because the training faculty,and ultimately the PD, is the one to assess whether the fellow hasprogressed appropriately, the responsibility of whether the fellowhad the actual ability to practice competently was the PD’s judg-ment call. Evaluations and assessments were performed, maybeusing a system in place at the academic center and certainly notalways in a standard fashion.

To try and make the fellowship experience more standardized,metrics for the quality of education and competency were added asanother requirement for fellows. In 1999, the Accreditation Councilfor Graduate Medical Education (ACGME) endorsed the 6 corecompetencies, which have become an integral part of the trainingand assessment of our residents and fellows: medical knowledge,patient care, interpersonal and communication skills, profession-alism, practice-based learning and improvement, and systems-based practice. Program directors and faculty evaluate the fellowson whether they have attained a specific level of competency inthese areas and whether appropriate progression occurs throughtheir training. On graduation the fellow must be able to showcompetency in these areas and independently provide care, or asthe guidelines state: “demonstrate sufficient competence to practiceallergy and immunology independently without direct supervi-sion.”2 As a result, faculty physicians working in academic institu-tions have all become familiar with these competencies becausethey have become incorporated at the medical school level; in fact,all allergists are now aware of them because they have beenincorporated into the American Board of Allergy and Immunologymaintenance of certification program.

Before the ACGME instituted the electronic case log system viaWebADS (ACGME’s web-based accreditation data system) in 2000,there was no uniform method for documenting patient diagnosesand conditions or procedures performed during fellowship. All thisprior documentation depended entirely on the fellows and the PDsthemselves. Documenting cases takes time, and the fellows maynot take the time to document the case information or numbersaccurately because of other priorities. The PDs still needed toconstantly remind the fellows to input their patient informationinto WebADS in a timely manner. The PD could see whether thefellow’s case logs were within the national norms, but there was nospecific number that would signify whether the fellow was able topractice independently. There were no minimum numbers ofspecific cases or procedures, but the important part was whetherthe training faculty and PD believed that the fellow had handled anappropriate number of cases or procedures to be deemed compe-tent. This system could still lead to large disparities in the trainingfellows received.

An attempt has now been made to try and make these experi-ences more standardized. In the most recent proposed changes tothe ACGME program requirements (scheduled to start in July 2014),the ACGME and our A/I Residency Review Committee are planningto incorporate updated specific program requirements for A/I thatwould involve a minimum number of diagnoses and proceduresthat are important for a practicing allergist/immunologist. There isa concern that if there is a minimum number that certain rareconditions or procedures may not be adequately handled bya fellow and would thus limit fellows from successfully graduating.However, our A/I Residency Review Committee is aware of this andplans to use the lower 10th percentile nationally from the prior caselogs to set these minimums. In addition, there is talk of allowingother innovative ways of learning about these rare conditions tocount toward evidence of competency.

Accreditation

Probably all allergists remember the dreaded site visit, whichwas the key component to the accreditation process in the old

system. In preparation for the site visit a program information formwas filed, which documented the curriculum, the faculty, andcompliance of the program with ACGME program requirements. Ifthere were any questions on the program or if serious citationswere given, the cycle length of the approval could be less than thecoveted 5 years. Between site visits, the program would beresponsible for all appropriate documentation. This approachmeant that most programs had a flurry of activity around the timeof the reaccreditation process but then were not necessarilyadherent to requirements in the outlying years of the accreditationcycle, other than the midcycle internal review performed throughthe institution’s graduate medical education officials.

To attempt to reduce the burden associated with the site visitsand to provide a more consistent oversight of the quality of thefellowship programs, a new accreditation process, the NextAccreditation System (NAS), will be implemented for A/I fellowshipprograms in July 2014. The NAS allows for less frequent site visits(optimal accreditationwould carry a cycle of 10 years). This reducedfrequency of site visits should reduce some of the burden on thePDs; however, the tradeoff is that documentation of the fellows’progress (ie, diagnoses and case logs), the program’s curriculum,and board pass rates, among other items, will be reported annuallyto ACGME. If after review of these items, the ACGME identifiesa concern, there will be an earlier site visit. The expectation is thatmuch greater oversight responsibility will fall on the graduatemedical education committee of the institution. Thus, it is hopedthat the NASwill achieve both aimsdreduce the burden on PDs andensure consistent quality in the fellowship training programs.3

Further, the evaluation of fellows will be changing, and the9-point scale (which seems to breed grade inflation) will be retiredand replaced by theMilestones Project. The Milestones Project usesnarrative terms with 5 levels to describe the fellow’s progresswithin the context of the general competencies. For example, level1 is a new learner, whereas level 5 is a master/expert. The fellow’sprogress will be assessed by core faculty who have spentaminimum amount of time (15 hours per week averaged for 1 year)with the fellow and can accurately assess the fellow’s progress. Inaddition, the Milestones Project will need to involve facultydevelopment, so the faculty are comfortable in accurate assessmentof the fellows and can use this new language, and likely will requiremore documentation. The primary specialties, such as internalmedicine and pediatrics, started using the Milestones Project onJuly 1, 2013.4

Changes in Learning

The process of adult learning must also be taken into consid-eration when creating a fellowship curriculum. In the 1970s, Mal-colm Knowles, a theorist and practitioner of adult learning, helpedidentify the 6 principles of adult learning: adults are internallymotivated and self-directed, they bring life experiences andknowledge to learning experiences, and they are goal oriented,relevancy oriented, practical, and like to be respected.6 Theseprinciples are important, in particular, because resources andtechnology have changed through the years. The PD Reading Listhas been an important part of the fellowship program’s curriculumand consists of articles (landmark, review, and cutting edge) thatPDs themselves would review and update in a 3-year cycle. In thelast few years, technology has advanced to include the websiteUpToDate, how to videos on the Internet, webinars, the Confer-ences Online for Allergy series (hosted by the A/I program atChildren’s Hospital in Kansas City and sponsored by AmericanCollege of Allergy, Asthma, and Immunology), eBooks, and otherforms of real-time learning. As such, the PD Reading List has notbeen as well used as it had in the past. In fact after much discussion,the Core Curriculum Education and Residency Review Committee

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voted to change the reading list from its current format. Althoughthe new format is still in the process of being decided, it isimportant to realize that today fellows and other house staff muchprefer to use resources such as UpToDate to answer questions inreal time, supplementing their learning later by reading theprimary articles.

Conclusion

As we have tried to document, the A/I training programs areconstantly evolving to meet the needs of each generation of aller-gist fellows. The continued motion has been to try and developa consistent high-quality education system that ensures that newlygraduated fellows are ready to start their independent allergycareers. The changes have incorporated the use of the NRMP for theapplication process, the use of the general competencies to betterdocument evaluation of the fellows and their abilities, and newtechnology and electronic resources that can be used to addressadult learning processes. Although many of these changes haveincreased the amount of documentation needed for fellowshiptraining and the amount of administrative time needed by the PDsin an era of health care driven by clinical productivity, they alsohave made the process more consistent across all programs. Inaddition, the hope of a 10-year accreditation cycle should helpreduce the burden placed on PDs. These changes all have helped toprepare our fellowship programs for the 21st centuryda time

when fellows no longer want to learn from didactic sessions onlybut want more interactive learning environments.

In conclusion, fellowship programs today are much differentfrom when they first started. The changes and requirements thathave been incorporated through the years have focused on betterdocumentation of competency, better tools and technology, and thesame ultimate goal of training an expert in A/I. Clearly, the A/Ifellowships are responsive to the changing educational environ-ment, but the question remainsdare these changes really leadingto better trained and prepared allergists? Only time will tell.

Acknowledgment

We acknowledge Mitch Grayson, MD, for his helpful suggestionsand review of the manuscript.

References

[1] www.NRMP.org/fellow/ensuring.html. Accessed June 16, 2013.[2] Common Program Requirements. ACGME Program Requirements for Graduate

MedicalEducationinAllergy/Immunology.http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/020_allergy_immunology_07012013.pdf. AccessedJune 17, 2013.

[3] ACGME-Next Accreditation System. http://www.acgme-nas.org/index.html.[4] ACGME-Next Accreditation System, Milestones. http://www.acgme-nas.org/

milestones.html. Accessed June 17, 2013.[5] Assa’ad A. Update from ERAS/NRMP Task Force. Paper presented at: Allergy and

Immunology Program Directors’ Annual Retreat; 2013; Chicago, Illinois.[6] Knowles M. The Modern Practice of Adult Education: From Pedagogy to Andra-

gogy. Cambridge, MA: Cambridge Book Co; 1998:43e44.