Friday, March 25, 2022

Clinical Informatics Subspecialty Practice Pathway Extended for Three Additional Years

A three-year extension to the Practice Pathway of board certification eligibility for the clinical informatics (CI) subspecialty has been approved by the American Board of Medical Specialties (ABMS) for the American Board of Preventive Medicine (ABPM). This is the second extension of the so-called "grandfathering" pathway that now allows physicians with a primary boarded specialty to achieve board eligibility without formal fellowship training through 2025. This means that physicians who desire to become board-certified in CI will be able to qualify to sit for the board examination by time working in the field or completing "non-traditional" training, the latter which may include a master's degree from a "24 month Masters or PhD program in Biomedical Informatics, Health Sciences Informatics, Clinical Informatics, or a related subject from a university/college in the US and Canada, deemed acceptable by ABPM (e.g. NLM university-based Biomedical Informatics Training)," such as the online Master of Science Program at Oregon Health & Science University (OHSU).

The CI field has expressed mixed feelings on this extension. In particular, a group of CI fellowship Program Directors published a letter in the journal Applied Clinical Informatics (ACI) opposing the extension, noting that the time for grandfathering has passed, and extending the practice pathway will adversely impact pursuit of fellowships.[1] I rebutted this letter, arguing that the field must find alternatives to two-year in-place fellowships to allow broader entry into the field.[2] In particular, a two-year in-place fellowship may place undue burdens on those who wish to become board-certified in CI long after they completed their primary training and would be unable to uproot from job, family, and/or other obligations.

Here are some snippets from my ACI letter arguing for alternatives to in-place fellowships:

I agree that we have passed the point where the Practice Pathway should allow physicians to become board-certified with essentially no formal training. However, I argue instead for this approach to be transformed into a method by where those who are unable to halt careers, salary, and family to pursue a pathway to certification that is mostly virtual and asynchronous yet still rigorous and supervised. Ironically, the pandemic has taught us that CI practice and education can be carried out in a mostly virtual format.

The in-place model for fellowship training made sense in the 20th century model of career development, where one completed education and training in their chosen profession and then entered the workforce for their career. In the 21st century, however, many professionals, especially in knowledge careers, change career pathways long after their primary education and training experience.

I oppose CI fellowships being completely remote, but it would be novel and innovative if there were some sort of hybrid training pathway, with fellows connected to an institution that could offer courses and allow supervised, mentored training experiences in healthcare organizations. Fellows would participate in a mostly remote way, but also have periodic in-person experiences, including stints that might be for several weeks or more and would involve direct interaction with faculty and colleagues. The field of Hospice and Palliative Medicine developed such an approach prior to the COVID-19 pandemic. Even CI somewhat emulates this approach now, as a half-dozen CI fellowships make use of online didactic courses from OHSU.

I applaud that for now the Practice Pathway will still allow those to pursue board certification. Hopefully the CI field can transition to a training process beyond the Practice Pathway that allows entry into the field without an in-place fellowship. As informaticians, we should be at the forefront of pioneering this approach in graduate medical education.

What are eligibility requirements for the CI subspecialty? They are essentially unchanged from the last time I posted about them in this blog in 2019, with the exception that the "grandfathering" pathway is now available through 2025.


1. Turer, R.W., Levy, B.P., Hron, J.D., Pageler, N.M., Mize, D.E., Kim, E., Lehmann, C.U., 2022. An Open Letter Arguing for Closure of the Practice Pathway for Clinical Informatics Medical Subspecialty Certification. Appl Clin Inform 13, 301–303.
2. Hersh, W.R., 2022. The Clinical Informatics Practice Pathway Should Be Maintained for Now but Transformed into an Alternative to In-Place Fellowships. Appl Clin Inform 13, 398–399.

Friday, March 11, 2022

Receding of the Pandemic: Will the Third Time Be the Charm?

Today, the Governor of Oregon is lifting the state's indoor mask mandate and ending the state's public health COVID-19 emergency. Like most US states, Oregon had a large Omicron wave of cases, hospitalizations, and deaths, although as through all of the pandemic still far below US national averages. At Oregon Health & Science University (OHSU), the number of patients in the hospital and ICU continues to fall each day. The mask mandate in non-healthcare buildings at OHSU will be dropped tomorrow and my department will return to some activities in-person with the start of the spring quarter at the end of March.

Will the pandemic finally recede now and allow us to return to an albeit new normal? We have been down this road before. The first came in the late spring and early summer of 2021. Vaccination had become relatively widespread, and the large wave of hospitalizations and mortality from late 2020 and early 2021 appeared to be subsiding. In Oregon, all mask and other public health mandates were lifted, and life seemed to be returning to normal.
Sadly, however, the Delta wave started in the late summer of 2021 and dashed hopes that the fall would see a return to relative normal. As the Delta wave subsided in the late fall, a second era of opportunity seemed to be coming again. Although somewhat more muted than the first reprieve, it looked as if a modified normal might occur in early 2022.

But then, of course, Omicron came, and with it a new wave of hospitalizations and mortality. One fortunate aspect of the Omicron wave is that there has been clear evidence that vaccination provides protection. Even if not preventing SARS-CoV-2 infection completely, vaccination does appear to limit the worst of the infection for most people.

Now the Omicron wave is receding, and hopefully the worst of the pandemic with it. Although some might be gun-shy to feel optimistic, it is clear that there can be a path to living with the virus and a new approach that balances public health requirements with individualizing risk. I look to those physician experts who express cautious optimism and allowing of individual decision-making within the extremes of those at the ends of the spectrum. My favorites include Ashish Jha, Bob Wachter, Leana Wen, and of course the prolific Eric Topol. I also believe that the federal government's new COVID-19 plan is reasonable, with its emphasis on vaccination, testing, and treatment. This is especially the case with new oral anti-viral treatments shown to be highly effective.

The most unfortunate aspects of this pandemic has been its politicization, it becoming part of the culture wars in the US. I am not unsympathetic to those who want to move on. I do not particularly enjoy wearing masks, even though I do so and will continue doing so when it is necessary to protect myself or others. It saddens me that one of the most speedy and effective vaccines ever developed is being met by so much resistance. In addition, the manipulation and misinformation is saddening for a medium I always hoped would lead to dissemination of communication and knowledge across humanity. Wishful thinking, I suppose.

I find particularly sad the misunderstanding of science and the gotcha politics of when knowledge changes based on new research. One of the best quotes comes from Mohamad Safa, an environmental activist who stated on Twitter: "Science is not truth. Science is finding the truth. When science changes its opinion, it didn't lie to you. It learned more."

As the pandemic recedes, what will be my approach? Being relatively healthy and in my early 60s, I would probably weather a COVID-19 infection reasonably well. I will not go out looking for one, but I also will not have dire fear of getting one. One irony about the pandemic period is that I have not been infected so much as a cold, which I normally get once to twice per year. I will also respect the public health concerns for COVID-19. I will not hesitate to wear a mask when I am asked to do so, especially when it protects someone who might be at higher risk of complications from infection. I will also continue to join the chorus of those advocating for more vaccine equity across the world.

The months ahead will be a large natural experiment in the United States, as mandates are lifted. We will see whether the collective immunity we have achieved through vaccination and natural infection will be enough to keep SARS-CoV-2 under control, especially those at highest risk of complications from infection.