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No Fellow Left Behind.

T he goal of the Dreyfuss model of skill acquisition is to achieve “mastery” (level 5) or expertise through life-long learning, with “competence” (level 3) serving as a pit stop along the journey.1,2 In the context of medical education, naturally, the attainment of competence gets paired with the completion of fellowship training. In this issue of the Journal of Bronchology and Interventional Pulmonology, Drs Wong and Knox3 take a brave stab at examining the current state of procedural competence among graduating pulmonary and critical care medicine (PCCM), pulmonary medicine, and critical care medicine (CCM) fellows. While the fellow’s procedural confidence is only a self-assessment and does not reflect competency (after all learners don’t know what they don’t know), it does reflect the real world. The authors also take a clever correlation with the fellowship directors’ global assessment on the current procedural competency requirement for each individual procedure and found a moderate concordance (78%) with fellows’ confidence at the same program. Notwithstanding the survey’s low response rate and other study limitations, its findings and conclusions should not be ignored. Perhaps most notably, graduating fellows were not uniformly ready for unsupervised performance of all the pulmonary and critical care procedures that one is assumed to have attained competence. In 2001, the US Congress had passed legislation for “No Child Left Behind Act.” This required schools to be accountable for student outcomes, shining a light on struggling students who get promoted up without the necessary tools to succeed.4 As medical educators, we must recognize the struggling fellows among our specialty and strive to leave no fellow behind. While there are diverging and strong opinions on the value of a threshold number fitting the procedural competence requirement for fellowship, at this time, the American College of Chest Physicians nonetheless recommends a certain minimum number of supervised procedures needed to attain competence in any given advanced pulmonary procedure.5 Arguably, until we have a true metric of individual fellows’ competency, the minimal training number should be on the higher side to ensure the public’s safety. After all, previous researchers have measured the incremental effect of each procedure toward improving a fellow’s procedural skills and highlighted the point that more is better even if the answer to “how many is enough” may be more complicated.6 Knox and Wang offer some insight on what this number may be by the program directors’ opinion on the number needed to achieve competency at the “strongly agree” level. In addition, similar to current education legislation, we should have accountability to our patients for programs that do not utilize available metrics, have sufficient procedural numbers, or remediation for fellows lacking their fellowship directors’ confidence. It seems contradictory that one federally funded education program