Evolving training to match a growing field

In recent decades, the field of infection prevention and control and healthcare epidemiology (IP&C/HE) has expanded considerably. ^{Reference Chiotos, Rock and Schweizer1} IP&C/HE programs are not only responsible for surveillance and prevention of healthcare-associated infections (HAIs), they also conduct cluster investigations, contribute to emergency preparedness, engage in quality improvement efforts, and partner with patient safety, occupational health, and environmental health and safety teams. They employ diagnostic and antimicrobial stewardship strategies, and they develop both patient and staff education. ^{Reference Kaye, Anderson and Cook2} The coronavirus disease 2019 (COVID-19) pandemic has only further highlighted the important roles of IP&C/HE and healthcare epidemiologists. ^{Reference Gupta and Federman3,Reference Banach, Johnston and Al-Zubeidi4}

As the field of IP&C/HE evolves in an increasingly complex healthcare environment, more demands are made on the healthcare epidemiologists who lead these programs. ^{Reference Wright, Ostrowsky, Fishman, Deloney, Mermel and Perl5} When IP&C programs were first developed, the physician team members made contributions from different backgrounds, including infectious diseases (ID), pathology, and microbiology, and not all had formal training in hospital epidemiology. These programs also varied in the amount of time dedicated. ^{Reference Wright, Ostrowsky, Fishman, Deloney, Mermel and Perl5–Reference Dembry and Hierholzer7} Although there is no formal accreditation process for healthcare epidemiologists, more ID physicians are seeking specific fellowship training in IP&C with the goal of a career in infection prevention as a healthcare epidemiologist, and healthcare facilities are offering positions with protected time to lead IP&C programs.

Existing training resources

There is no Accreditation Council for Graduate Medical Education (ACGME) fellowship, other formal accreditation, or certification process for training to be a healthcare epidemiologist. The ACGME requires all ID fellows to have some training in infection prevention, including competence in the diagnosis and management of HAI and device-associated infections, as well as infections, as well as general knowledge of infection control and hospital epidemiology. ⁸

Other educational opportunities include the Society for Healthcare Epidemiology of America (SHEA)/Centers for Disease Control and Prevention (CDC) Training Certification in Healthcare Epidemiology, ⁹ the SHEA Primer on Healthcare Epidemiology, Infection Control, and Antimicrobial Stewardship (online ID fellows’ course), ¹⁰ and the Annual Fellows’ Course in Healthcare Epidemiology, Infection Prevention, and Antimicrobial Stewardship (in-person course). ¹¹

Most ID fellows interested in a career in infection prevention seek out ID fellowship programs comprising an experienced hospital epidemiologist mentor and a strong IP&C program with a history of training ID fellows who have successfully launched careers as healthcare epidemiologists. Some of these programs have defined tracks in IP&C and may offer a third year of fellowship dedicated to additional IP&C training and research. The last SHEA membership survey published in 2010 found that while nearly 60% of respondents reported completing the SHEA/CDC training course, only 26% completed at least 1 year of dedicated IP&C training. ^{Reference Wright, Ostrowsky, Fishman, Deloney, Mermel and Perl5}

At a series of national meetings, ID division chiefs and program directors recommended either a 1-month rotation in IP&C and/or course involving a combination of didactic and/or practical IP work. ^{Reference Joiner, Powderly and Blaser12} They did not define what should be included in the rotation or the didactics. Subsequent surveys of both adult and pediatric ID fellows and recent graduates highlighted the importance but shortcomings of IP&C training during fellowship. Only half of adult ID fellowship respondents thought IP&C training was adequate, and pediatric ID fellowships were reported to be deficient in both the breadth and depth of IP&C training in most programs. ^{Reference Joiner, Dismukes and Britigan13,Reference Sandora, Esbenshade and Bryant14} In at least one institution’s published experience, a month-long semistructured rotation can be successful in improving IP&C education among ID fellows. ^{Reference Sreeramoju and Fernandez-Rojas15}

A proposed structured training model

To standardize IP&C education for ID fellows at our institution and to ensure that key competencies are met, we developed a training model enumerating competencies for ID fellows entering IP&C/HE fields (ie, “track” competencies) and non-IP&C/HE fields (ie, nested “rotation” competencies), with concrete activities to achieve each (Table 1). The competencies were adapted in part from a published SHEA white paper outlining healthcare epidemiologist skills and competencies, as well as our professional medical education experience. ^{Reference Kaye, Anderson and Cook2}

Table 1. Infectious Diseases Fellowship Infection Prevention & Control/Hospital Epidemiology Rotation and Track Core Competencies and Activities

Critically, these learning goals do not stand alone. During the IP&C/HE fellowship experience, each fellow is embedded with the IP&C team, spending dedicated time learning directly from infection preventionists, participating in observations and multidisciplinary work, and conducting analyses and quality improvement projects that promote patient safety. For fellows in fellowship training tracks (eg, antimicrobial stewardship, antibiotic resistance research, transplant ID, HIV and outpatient care, and physician-scientist), the competency activities and all other experiences are tailored to professional goals in these areas (eg, fellows interested in transplant ID may use ventricular assist device-associated infections as a case study to understand device-associated infections more broadly). This standardized, yet flexible, curriculum will help each fellow obtain a comprehensive IP&C education while allowing focused time on key areas of interest. This approach is mirrored in educational programs for other trainees, such as students pursuing a master’s degree in public health.

Continued evolution: A living training collaborative

In this commentary, we have shared one potential framework toward formalizing the ID fellow’s training experience. Others are invited to use the competency checklist in their program (available for download at https://dom.pitt.edu/id/training/fellowshipprograms/idfellowship/programstructure/clineducpathway/). We welcome an ongoing conversation in our IP&C/HE community about the development of ID fellowship training for nascent hospital epidemiologists, including improvements upon this model, adaptations for other IP&C and healthcare epidemiology career pathways, and a medical education research agenda testing the effectiveness of this and other educational strategies.