The American Board of Pediatrics’ (ABP’s) new model for competency-based pediatric subspecialty training that includes an option for a 2-year clinically oriented pathway has generated both applause and concerns as leaders prepare for a new landscape of training programs.

Leaders of ABP-certified subspecialties have been preparing for years to fully implement a competency-based medical education (CBME) system starting in 2028. And on the ground, programs have been transitioning to varying degrees to the use of “entrustable professional activities” (EPAs) — patient-oriented outcomes that define activities expected of subspecialists in practice — and other principles of CBME for several years. The ABP, in turn, has conducted pilot projects to evaluate and revise EPAs.

The new training model announced by the ABP in April takes it further with a more comprehensive assessment system and with curricular changes, such as increasing clinical time to 18 months, that it sees as important for CBME and readiness for unsupervised practice.

These changes lay the groundwork, the ABP says, for subspecialties and programs to adopt 2-year clinically oriented training pathways if they wish.

The CBME model “should open the door for new pathways to shorten the total training time,” said David A. Turner, MD, vice president for Competency-Based Medical Education for the ABP.

Except for pediatric hospital medicine specialists, ABP-certified subspecialists have until now been trained through a single model of 3-year training programs that prepare them mainly for academic careers involving both research and clinical care.

The ABP has been “trying to address multiple longstanding issues at the same time,” Turner said in an interview. “First and foremost is to advance a more patient-oriented, outcomes-focused approach to training…and to address what we know, based on research and from the community, are gaps in readiness to practice using the current approach.”

Addressing documented inequities associated with assessment has been another goal, as has improving children’s access to qualified subspecialists through more flexible training paths, Turner said.

“A competency-based approach can be a facilitator for a more equitable system,” he said in the interview. “And in the current context, we really need to make sure we have qualified pediatric subspecialists out there to care for children.”

In a 2023 report on the future pediatric subspecialty physician workforce, the National Academies of Science, Engineering, and Medicine recommended that the ABP and partner organizations develop a 2-year option for future subspecialists wanting to focus on clinical care. Within its broader goal of ensuring readiness for practice, the ABP wanted to “respond to that charge,” according to an ABP press release.

The ABP sees its model as a “blueprint” and the start of collaboration with the subspecialties to address questions and concerns, to flesh out details, and to “co-create implementation plans,” Turner said.

Diverse Subspecialties Means Diverse Changes to Come

The complexity of reaching consensus across subspecialties has been daunting, said Turner and Debra M. Boyer, MD, a pediatric pulmonologist who chaired a Competency-Based Subspecialty Training Task Force charged with advising the ABP last fall on possible approaches for incorporating CBME principles within a time-based system.

“All of the 15 subspecialties that are part of the ABP are very different. Some are only outpatient, some are only inpatient, and some [are mixed]. Some are very procedurally oriented. Some have a higher number of folks who do more clinical work vs research. Some have private practice opportunities; others don’t,” said Boyer, chief medical education officer and designated institutional official at Nationwide Children’s Hospital in Columbus, Ohio.

“And they vary in the amount of clinical training they typically do,” she said. For many subspecialties, she said, the newly required 18 months of clinical training is an increase.

Turner and Boyer both said they subsequently anticipate a future with a mixed landscape of 2-year training pathways and 3-year scholarship-oriented pathways across subspecialties — and even within them.

“There may be subspecialties that have few or no programs electing the 2-year option because they don’t think it’s feasible for a variety of reasons,” Turner said, “and it’s unlikely, but there may be some that will have entirely 2-year programs.”

Pediatric rheumatology is among the subspecialties that have long been pushing for a shorter clinically focused training track to help bolster the pediatric rheumatology clinical workforce and improve patient care access. One hope is that recruitment into pediatric rheumatology can be improved with training that is shorter and less costly.

“We’re focused on competency, but we’ve firmly believed we could work toward a shortened training time,” said Ekemini Ogbu, MD, MSc, who chairs the American College of Rheumatology’s Pediatric Rheumatology Committee.

“We’ve had discussions weighing the pros and cons for a very long time,” said Ogbu, of Cincinnati Children’s Hospital Medical Center and the University of Cincinnati. “I think most people in our field have been inclined to agree we can achieve competency [for practice] in [fellowships lasting] less than 3 years,” as adult rheumatologists and others do.

Pediatric infectious diseases (ID) specialist Scott H. James, MD, of the University of Alabama at Birmingham, on the other hand, said he and others in the subspecialty “are thinking positively in general about flexible training pathways but have a lot of concerns and questions.”

For instance, “if the third year becomes optional, how can we ensure there will be funding guaranteed for that third year of advanced training or scholarship-focused training?” James said in an interview. “If 2 years becomes the minimum, will GME [graduate medical education] offices or institutions…tell trainees and their program directors to go out and get extramural funding to cover the third year?”

Pediatric ID is “a very academically based pediatric subspecialty,” he noted. “High levels of academic scholarship are very important to us as a subspecialty” and the needs of our patients. Fewer trainees pursuing a 3-year scholarship pathway, he worries, would threaten an already shrinking pipeline of physician-scientists in peds ID and other subspecialties.

Their current training model includes 1 year of clinically based training and 2 years of training focused on research and scholarship. Trainee well-being in a new construct with 18 months of clinical time in a 2-year period is a concern, James said, as is a potential future mismatch with the job market and peds ID workforce if clinically focused training pathways were to become widely embraced.

Protecting Pediatrician-Scientists

Sustaining research training and a physician-scientist pipeline is a priority for pediatric rheumatology as well, Ogbu said.

And it’s firmly on the ABP’s radar screen, Turner said, as is the desire for trainees who pursue a clinically oriented pathway to still engage in scholarly activities, contribute to science, and understand how to use and apply evidence in practice.

To enable increased clinical time, the ABP is doing away with its requirement for a “scholarly work product” (eg, a manuscript publication) for all fellows and is instead addressing scholarship through a broadly defined “scholarship activity” EPA.

Implementation details for research and scholarship in both 2- and 3-year pathways are among the details that ABP and subspecialty leaders will discuss over the coming weeks and months, Turner said.

“As we think about how to handle scholarship for those [pursuing] a 3-year pathway,” he noted, “we can think about how we can achieve a depth of research and prepare physicians for future academic careers in a way we haven’t before. We see it as a substantial opportunity.”

Boyer is part of the National Pediatrician-Scientist Collaborative Workgroup and said the group has “already had lots of conversations with the ABP and with the Association of Medical School Pediatric Department Chairs,” the latter of which is integral to the provision of funding for training and early career faculty starting research careers.

Introduction of a clinically focused pathway poses a “potential risk” to the pediatrician-scientist pathway, Boyer said, “but as long as we’re thoughtful about it and continue to focus on it, I’m confident we’ll be able to maintain it.”

Within her subspecialty of pediatric pulmonology, it is likely, she said, that some training programs will have “more of an interest in training clinically oriented fellows, while other programs with a lot of research resources or advanced medical education resources will wish to train fellow for 3 years.”

Like the majority of pediatric subspecialists, most pediatric pulmonologists work at academically affiliated children’s hospitals. In her specialty’s case, she said, “even those who choose the 2-year pathway will likely [still] work at children’s hospitals…in more clinically oriented roles.”

“We’ll see how it plays out in the future,” she said. “This is a new era, and we’re all going to learn together.”

New Workplace-Based Assessments

Discussions with experts from Canada, “which is ahead of the US by a number of years in their implementation of CBME,” have been valuable, Turner said, as the ABP has worked to fully develop a CBME system for the pediatric subspecialties and for general pediatrics as well.

Connections with other specialties in the US that “are rapidly advancing CBME,” such as surgery, family medicine, and orthopedics, also have been beneficial, he said. “There’s a ton of connection across the specialties as we think about how to advance this work.”

In a comprehensive CBME approach, trainees advance based on their demonstrated achievement of competency, and learning is individualized. “Whether you’re training fellows for 2 years or 3 years, there’s a need to demonstrate through a variety of assessment methods that your fellows have achieved competency,” said Boyer, who directed the pulmonary medicine training program at Boston Children’s Hospital for 17 years before moving to Nationwide Children’s Hospital.

Assessment methods outlined by the ABP include workplace-based assessments (“micro-assessments”) to be completed by at the time of or immediately following a clinical encounter and longitudinal tracking of individuals’ progress with EPAs.

EPAs are observable everyday activities that pediatric subspecialists should be able to perform, such as “providing consultation to other healthcare providers” and “leading interprofessional teams to provide collaborative, family-centered care.” In addition to these common EPAs, each subspecialty has developed its own EPAs as well.

Research published in 2025 by the ABP in collaboration with subspecialty training programs showed that in the current training paradigm, many trainees were not deemed ready to graduate from fellowship after 2 years and did not feel ready themselves. “It makes sense, as 3 years is the trajectory,” said James, a co-author of the research paper. “But what it showed us is that if we’re considering moving to a 2-year model, it [requires] a compete restructure and redesign of the curriculum.”

The newly approved CBME model — with its framework of EPAs and its new, more robust curricular and assessment elements — should facilitate this restructuring of training and subsequent readiness, Turner said.

The ABP is building resources and curricula for program directors to implement the model, he said, and is working with the Accreditation Council for Graduate Medical Education to align requirements, including its Milestones 2.0, in hopes of full implementation for fellows entering training no earlier than July 2028.

None of the physicians quoted in this story reported having any relevant financial disclosures.