Promotion in Place (PIP) FAQ

Promotion in Place” (PIP) is a model of competency-based, time-variable (CB-TV) training in which trainees become Board-admissible (meaning they will be provided with access to the exam applications and evaluated according to all ABS requirements except for the time in training requirement), when they are deemed competent/practice ready. These trainees then graduate and become fully credentialed attendings with billing privileges until what would have been their standard graduation date, allowing them an independent experience serving as an attending while “sheltered” in their training institution.

The fully credentialed PIP-SI attending is completely independent from the ACGME training program and is not associated with the ACGME’s Accreditation Data System (ADS). The PIP-SI attending must have attending-level malpractice coverage, the same as other attendings at the same institution.

The program director, selected trainee, and clinical service chief will develop a schedule that is beneficial for the PIP-SI attending’s career development. The default scope of practice will be a core general surgery experience.

The program’s Clinical Competency Committee (CCC) will determine competency and readiness for graduation from the program. Proposed metrics for graduation include ABS Case log minimums; Fundamentals of Laparoscopic Surgery (FLS)/Fundamentals of Endoscopic Surgery (FES)/Advanced Trauma Life Support (ATLS); deemed practice-ready for all EPAs*; meeting standards for ACGME Milestones; passing the General Surgery Qualifying Exam; and multisource feedback evaluations assessing all six core competencies including teamwork, communication, and professionalism.
*EPAs with fewer than 0.5% of collected assessments will be exempted from this requirement.

The ABS will need to waive the time in program requirement for Board admissibility and has conceptually agreed to do this in the context of the PIP pilot. At the time the individual program has decided that the PIP participant is ready to graduate and enter the period of sheltered independence, the ABS will allow these individuals access to the certification pathway. The PIP team will provide guidance in this process.

The time allowed for PIP-SI for the proposed pilot is 6 months.

One of the central tenets of PIP is to allow appropriate autonomy once a trainee graduates early from the program and remains in the familiar environment of their training program surrounded by those that have been instrumental in their training. This contrasts with the transition to independence which often occurs in a new institution, with unfamiliar surroundings, colleagues, and modes of practice.

Trainees who need extended time to meet competency standards will have graduation delayed. This is consistent with the standards outlined in the ACGME Common Program Requirements. The PIP model advantages all residents by emphasizing competency-based assessment and, thus, the ability to identify and support struggling residents early in training.

No, the competency assessments are the same for all residents in the program. Programs involved in PIP must have a robust process for competency-based assessment.

All trainees in the program must be eligible for PIP-SI consideration. Qualified trainees can accept or decline an offer to graduate early and those who decline remain in the standard program.

Enhancements in trainee assessment have been achieved via EPAs, Milestones, formal intraoperative assessments, multisource evaluations, etc. Implementing these processes requires upfront effort from faculty and CCC members but, once in place, PIP is a natural outcome of and dependent on this level of rigorous assessment.

There is always the risk that there will be unintended consequences to any innovation. However, the goal of Promotion in Place is to allow the PIP-SI attending to take the next step in their life-long learning with enhanced autonomy while in the confines of their training institution and mentors.

The PIP-SI attending has privileges which will include those that most other new attendings are given in their department, i.e. privileges that do not require additional training beyond completion of the residency.

To qualify for PIP-SI, one must demonstrate professionalism and self-awareness. As with any new attending, if the PIP-SI attending has limited experience in a case, they would request consultation with a more experienced colleague. Thus, the breadth of experience of the PIP-SI attending would continue to grow as it would during the early years following residency.

While the salary and benefits remained at the individual’s final year of training during the initial pathology PIP-SI pilot, this has varied in subsequent pilots. We anticipate that there will be further considerations and discussion by each independent department and institution as to the appropriate salary and benefits for the PIP-SI attending. We cannot provide any guarantees regarding potential compensation for the PIP-SI attending.

The current proposal recommends that all subspecialty and ACGME requirements be completed before graduation and the 6-month PIP-SI attending experience.

Board certification is contingent upon completing the 6-month period as an attending at the same institution.

PIP-SI attendings have met rigorous criteria for graduation from their GME training program, are deemed Board-admissible, and are credentialed as attendings. They will undergo the same period of Focused Professional Practice Evaluation (FPPE) monitoring as do all new attendings as required by the Joint Commission. Following an approved pathway and creating appropriate documentation are designed to mitigate risk, but there are unknowns with any innovative or novel approach.

Approximately 6-9 months ahead of the anticipated graduation, residents will need to apply for a full state medical license, DEA license, hospital credentialing, payor onboarding, and malpractice coverage in accordance with all applicable state laws and regulations. Please refer to your individual institution’s registration policies.

The PIP-SI attending is like any Board-admissible, credentialed new attending who has been deemed competent by their training program.

Promotion in Place is an interim step on the path to CB-TV training in which the period of residency/fellowship could be shorter, standard time, or longer depending on when competency is achieved. Gathering pilot data on feasibility, acceptability, patient safety, trainee wellness, competency achievements, morale, and other important outcomes will be essential.

PIP is one of the first innovations nationally that seeks to implement and evaluate CB-TV training. It offers residents the possibility of graduating early and transitioning to “sheltered independence” in a familiar environment. It also allows us to gain experience with such a model, learn from it, and advance the field of medical education and GME.

There is currently experience with Promotion in Place pilots in three specialties: Pathology at Massachusetts General Hospital launched PIP in 2021 and by 2025 had 18 residents graduate early into a period of sheltered independence; Plastic Surgery at the University of Pittsburgh and Johns Hopkins started a CB-TV process in 2018 and Johns Hopkins is graduating the first PIP-SI attendings; and Ob-Gyn at the University of Michigan launched PIP in the Spring of 2025. A qualitative stakeholder analysis of the PIP-SI pilot in Pathology found that PIP-SI has value in workforce readiness, satisfaction, and well-being and that it promoted independent decision-making.