The Blue Ribbon Committee (BRC) II has identified Promotion in Place (PIP) as a proposed model for enhancing autonomy and judgment in general surgery training,1 assisting in the transition to fellowship and practice, and exploring a competency-based, time-variable (CB-TV) approach to resident education.
In the PIP model and CB-TV approach, trainees become American Board of Surgery (ABS)-admissible when they are deemed competent and practice ready. An ABS-admissible candidate is a participant who is provided with access to examination applications and evaluated according to all ABS requirements, except for the time-in-training requirement.
Qualified trainees then voluntarily graduate early and become fully credentialed attendings with billing privileges until what would have been their standard graduation date. This structure allows the individual an independent experience serving as an attending while “sheltered” in their training institution.
In its first year, the PIP model permits up to 6 months of experience in a sheltered independent (SI) practice. Thus, the fully credentialed PIP-SI attending is completely independent from the Accreditation Council for Graduate Medical Education (ACGME) training program and is not associated with the ACGME Accreditation Data System (ADS).
Initial findings support the use of PIP-SI in the specialties of pathology, obstetrics and gynecology, and plastic surgery.2-5 After approximately 1 year of preparation and with the support of the ACS, ABS, ACGME, American Surgical Association, and Association of Program Directors in Surgery (APDS), PIP will be implemented as a multicenter, multiyear national pilot during which feasibility, acceptability, and outcomes of the PIP-SI model of CB-TV training in general surgery will be evaluated.
Pilot Objectives and Execution
Voluntary participating programs will be selected through an application process. All trainees in participating programs will be assessed uniformly for a PIP-SI role. The program’s Clinical Competency Committee (CCC) will determine competency and readiness to graduate from the program based on specific metrics.
After identification of practice readiness by the CCC, a qualified trainee may accept or decline an offer to graduate early. Those who decline will continue in the standard training program.
Once a PIP-SI candidate is selected, schedules are adjusted so that all specialty services and ABS and ACGME requirements are completed prior to initiation of the PIP-SI experience. Adjustment of these schedules also is intended to allow the future PIP-SI attending to have a “chief experience” during the last 6 months of the fourth year and the first 6 months of the fifth year in training.
Following selection, a 6-9-month ramp-up period prior to the anticipated graduation date is necessary as the incoming PIP-SI attending will need to apply for a full state medical license, Drug Enforcement Administration license, hospital credentialing, payer onboarding, and malpractice coverage in accordance with all applicable state laws, regulations, and institutional policy. An experienced PIP team will guide these efforts.
The program director, selected trainee, and clinical service chief will develop a plan for the PIP-SI experience that is beneficial for the PIP-SI attending’s career development. The default scope of practice will be a core general surgery experience. Each training program will have individual circumstances that determine the best configuration of a PIP-SI experience. However, the central tenet of PIP-SI is to allow an autonomous experience in the familiar environment of their training program surrounded by those who have been instrumental in their training once a trainee graduates early from the program. This structure contrasts with the transition to independence that often occurs in a new institution, with unfamiliar surroundings, colleagues, and modes of practice.
If the PIP-SI attending has limited experience in a case, they would request consultation with a more experienced colleague, as one would expect with any new attending. Thus, the breadth of experience of the PIP-SI attending would continue to grow as it would during the early years following residency. The PIP-SI attending must remain in the training institution until the standard graduation date as a requirement for ABS certification.
Critical to the success of the PIP pilot is a robust CCC that can make high-stakes decisions regarding practice readiness as well as faculty and trainee development in the form of feedback and assessment.
Enhancements in trainee assessment already have been achieved via Entrustable Professional Activities (EPAs), Milestones, formal intraoperative assessments, multisource evaluations, and so on, which provide a plethora of sources for CCC appraisal. We expect that one of the benefits of the PIP program will be enhancement in assessment, evaluation, and feedback processes to the betterment of all trainees, including those that are excelling, but also those who may be struggling.
Programs are currently being identified for the pilot with plans for the first PIP-SI experience to begin January 2028, with new programs added on an annual basis.
As the pilot develops, we are intent on creating a community of centers to identify best practices, share ideas, and create processes for successful implementation. The need to be flexible in applying the PIP-SI experience to each program is paramount while principles of enhanced autonomy and experience in the attending role are maintained.
The BRC II invites all interested institutions to contact the PIP team to discuss participation in the pilot. Learn more at facs.org/for-medical-professionals/education/programs/promotion-in-place-pip-pilot or contact PIP@facs.org for additional information and to request an application. View the full FAQ for this program at facs.org/for-medical-professionals/education/programs/promotion-in-place-pip-pilot/faq.
Looking Ahead
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 work to advance medical and surgical education as a whole.
PIP is an interim step on the path to CB-TV training in which the period of residency/fellowship could be shorter, standard, or longer depending on when competency is achieved. Gathering pilot data on feasibility, acceptability, patient safety, trainee morale, competency achievements, and other important outcomes will be essential.
