We appreciate the Letter to the Editor by Goldhamer and Co regarding our Perspectives article1 addressing “Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education.”2 The Letter to the Editor suggests we mischaracterized “PIP participants in ‘sheltered independence’ as residents, which they are not: they have officially graduated from the residency program and are fully credentialed as attendings.”
In the Promotion in Place (PIP) model, residents who meet competence criteria early may have technically “graduated” from their residency programs. However, their options are limited to continuing as residents in the program, or credentialing as attending physicians with “sheltered independence,” at their home institution until the standard graduation date. As such, the features traditionally associated with completion of residency training, such as the ability to initiate fellowship training or to establish an independent practice of choice are missing in this model.
The Accreditation Council for Graduate Medical Education requires program directors to sign a final evaluation for each resident upon completion of the program, stating the resident “has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice.”3 It is unclear why residents who have “graduated” from a residency, assumedly with attestation to support their fitness for autonomous practice, should be required to continue as a resident or be restricted to serve as an attending physician at only the institution that sponsors their residency.
Our concern about potential confusion related to a “dual role” as resident and attending is based on the description of flexible engagement in attending and resident-level activities during the “sheltered independence” of the attending appointment. The authors describe a hypothetical case in which a PIP participant completed “scheduled elective cardiology and renal subspecialty consult rotations—acting in a resident role—based on desire for that additional subspecialty education.” In essence, the PIP participant who has been credentialed as an attending physician might serve at least part of their time functioning at a supervised resident level. As such, the attending would be functioning interchangeably in a resident role.
We are confident the PIP model described by Goldhamer et al did not exploit residents, and we acknowledge the safeguards associated with specialty-specific board and other regulatory approvals. Similarly, it is clear the authors ensured transparency of roles and appropriate billing for services. Our comments in this regard are primarily focused on the potential for exploitation should the PIP model be generalized across other sponsoring institutions that may lack the discipline associated with the carefully designed protocol and/or the robust individualized trainee assessment on which the model depends.
The PIP model may also be limited in its fair application. For example, a talented resident who did not have a core rotation scheduled until the end of training might not qualify for PIP consideration compared to a colleague with a more favorable schedule. Motivation could also exist to exploit circumstances based on assignments that prioritize institutional needs over educational considerations.
We also encourage ongoing informed debate about competency-based, time-variable graduate medical education (GME) and accurate characterization of innovative models such as PIP. Although limited to a single specialty residency program at a single institution, the PIP model described adds an important piece to a complex puzzle. This and other models merit further consideration in our collective efforts to ensure our systems of GME provide the competent professional physician workforce required to serve our patients and society.
