A 20th Century Model of Education for a 21st Century Profession? OHSU Response to ACGME Draft Requirements for Clinical Informatics Fellowship Programs

As noted last month, the Accreditation Council for Graduate Medical Education (ACGME) released draft requirements for clinical informatics fellowship programs in late July, with a 45-day comment period that ended last week. A group from Oregon Health & Science University (OHSU), including myself, some other informatics faculty, our Senior Associate Dean for Education, and our Associate Dean for Graduate Medical Education submitted a response to ACGME.

The bottom line, as the title of this post says, is that the proposed ACGME approach really applies an increasingly outdated 20th century model of medical training to the vibrant 21st century subspecialty of clinical informatics. There is no question that clinical informatics training, like any other training, requires knowledge, skills, and experience. But the standard time-based, in situ approach to training likely will not build the capacity needed or provide a pathway that many who seek to join this profession can take.

One irony of this sort of approach is that OHSU was just awarded one of 11 grants from the American Medical Association (AMA) in their Accelerating Change in Medical Education initiative. Three schools, including OHSU, have as one of their aims for the grant to move medical education from a time-based to competency-based approach. There is no reason why every medical student has to spend exactly four years in school. Some may have backgrounds that allow them to accelerate their pace, which will be helpful as the need for physicians grows due to aging baby boomers and healthcare reform.

In a posting last year, I expressed concern about a time-based, in situ approach, which not only may limit the growth of capacity in the subspecialty, but also lock out a pathway to the profession for those who cannot disrupt work, families, or other aspects of their lives to uproot their lives to pursue a site-based clinical informatics subspecialty. OHSU has trained many physicians and others who have gone on to successful informatics careers using a mostly distance-based approach.

There are other problems that our response noted as well. A key one is the limitation of programs being administratively linked to the six specialties of Anesthesiology, Emergency Medicine, Medical Genetics, Pathology, Pediatrics, or Preventive Medicine. While this does not mean that physicians of any specialty will not be allowed to participate in a fellowship, we expressed concerns programs may be beholden to the affiliated specialty, either philosophically or fiscally, who may impose demands that could compromise the clinical informatics training experience. In addition, it may be difficult for trainees of specialties outside the affiliated one to pursue clinical work in their own specialty within the fellowship in a given institution that has a fellowship linked to a specific specialty.

We also expressed concern that clinical informatics fellows might not be able to practice their specialty as attending-level physicians and bill for their work. Being able to bill for practice in their primary specialty will be important not only for fellows’ maintaining clinical skills in their primary specialty but also for financial viability of the fellowship program.

We will eagerly await the ACGME response to ourselves and others who replied to their draft. In the meantime, planning will move forward for a clinical informatics subspecialty fellowship at OHSU. We also hope to work with other programs who seek help in providing educational content in their programs.