To the Editor: In Response to “A Perspective on Promotion in Place and Competency-Based, Time-Variable Graduate Medical Education” Open Access

As authors of “Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education,”¹  we read Rose and Long’s Perspectives article about this publication with great interest—and concern.²  Our “Innovation Report”¹  describes a model for extending training when needed, and for allowing residents who have achieved full competence to graduate early into an attending role at their residency institution. Unfortunately, the Perspectives article fundamentally misunderstands the Promotion in Place (PIP) model and therefore misrepresents it and raises concerns that are not relevant to the actual model as described.¹ 

Rose and Long misunderstand a fundamental aspect of the model by mischaracterizing PIP participants in “sheltered independence” as residents, which they are not: they have officially graduated from the residency program and are fully credentialed as attending physicians. Our Innovation Report states that “Residents deemed competent for early graduation may transition to attending physician status within their training institution and act in that capacity until the standard graduation date.”¹  The word “may” reflects that residents offered early graduation (based on meeting criteria) can accept or decline.¹  To illustrate: “sheltered independence” participants in an ongoing PIP pilot at Massachusetts General Hospital (MGH) are officially graduated from the residency program, registered with the specialty board, and appointed as attending physicians at MGH. Thus, concerns raised about “exploiting” residents²  via “sheltered independence” are simply not applicable to this model. Likewise, a conflicting “dual role”²  of resident and attending does not exist since those participating in “sheltered independence” are attending physicians—even if they choose to retain some learning opportunities typically provided to senior residents,¹  similar to opportunities and oversight that many institutions provide to new attendings. Importantly, Rose and Long’s additional concerns about billing fraud also rests on their misinterpretation of the model as involving a “dual role.”² 

The Perspectives article’s authors note potential concerns about transparency with respect to newly graduated attendings in communications with patients.²  We point out that PIP graduates have met criteria for residency graduation and credentialling as attending physicians. Moreover, graduates of variable clinical training through the American Board of Internal Medicine’s decades-long clinical-investigator pathway are not flagged for patients.

Rose and Long express concern that the PIP model “risks prioritization of rotations and experiences based on institutional clinical needs, gaps in attending schedules, and profitability at the expense of educational interests.”²  Indeed these risks apply to residency education generally, where service needs can override best educational practices. PIP’s “sheltered independence” is designed for tailored progression of attending-level responsibilities with workload adjustment appropriate for new attendings.¹ 

Rose and Long propose hypothetical cases²  that are nothing like the PIP core model¹  described in our report, or its initial implementation. The potential pitfalls of these hypothetical cases, amplified in a visual abstract,²  may mislead readers not directly examining the details. Adoption of the PIP model by other specialties and institutions requires specialty-specific board and other regulatory approvals.¹ 

The rigorous, developmental, and individualized trainee assessment process core to the PIP model¹  aims to ensure that all graduate medical education (GME) graduates are competent and ready for independent practice. Indeed, this was underscored in a stakeholder analysis that examined the value of PIP.³ 

We encourage informed debate about competency-based GME and PIP to help refine new educational models and compare them to our far-from-perfect current model.^4,5  We also encourage scrutiny and transparent reporting of PIP outcomes from programs motivated to evaluate potential advances in GME. At the same time, accuracy in characterizing each model is essential.