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Fellowship Training For The Future Clinical Microb - 230317 - 202132
Fellowship Training For The Future Clinical Microb - 230317 - 202132
Fellowship Training For The Future Clinical Microb - 230317 - 202132
F u t u re C l i n i c a l M i c ro b i o l o g y
L a b o r a t o r y D i re c t o r
Bobbi S. Pritt, MD, MSca,b,*, Carrie A. Bowler, MS
b
,
Elitza S. Theel, PhDa
KEYWORDS
Graduate Medical Education Clinical Microbiology Fellowship Public Health
Training
KEY POINTS
Clinical microbiology laboratory directors play an essential role in ensuring high-quality,
relevant, cost-effective, and safe diagnostic testing, compliant across regulatory bodies.
Medical and public health microbiology (MPHM) fellowship training plays a highly valuable
role in preparing future clinical microbiology laboratory directors for their leadership and
management responsibilities.
Given the continually evolving MPHM field, fellowships must remain adaptable to such
changes and advances, providing trainees with the opportunity to engage with newly
emerging diagnostic modalities, while continuing to emphasize the “bread and butter”
techniques of clinical microbiology.
INTRODUCTION
The clinical microbiology laboratory occupies an essential role in the health care sys-
tem, contributing to the diagnosis, treatment, prevention, and control of infectious dis-
eases.1 Full-service laboratories provide a broad spectrum of low, moderate, and high
complexity tests for the detection and characterization of bacterial, viral, fungal, and
parasitic pathogens using conventional and advanced diagnostic techniques. Testing
services directly support patient care, guide institutional antimicrobial stewardship ef-
forts,2 sustain systems for infectious disease surveillance,3 aid in the detection of
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522 Pritt et al
outbreaks, and support public health disease reporting. Collectively, these services
directly support patient care, while also shaping policy and practice decisions across
the institutions and communities that it serves.
Given the complexity and scope of services provided, it is essential that the clin-
ical microbiology laboratory director have the skills, knowledge, and experience
needed to carry out their responsibilities in support of the institution’s mission.
These responsibilities are numerous4 and are outlined at the most basic level by
Standard 493 Subpart M of the Clinical Laboratory Improvement Amendments
(CLIA) of 1988 in its description of Technical Supervisor responsibilities for non-
waived testing.5 First and foremost, the clinical microbiology laboratory director
(ie, CLIA technical supervisor) serves as an essential member of the clinical care
team, ensuring that the laboratory provides high-quality, timely, relevant, cost-
effective, and safe testing in compliance with local and federal regulatory bodies.
In this role, the laboratory director defines the scope and contents of the laboratory
test menu, establishes or verifies test performance characteristics before clinical
implementation, designs and implements a quality management system to ensure
ongoing accurate and timely test results, and provides consultative services to aid
in test selection, specimen collection, and result interpretation. The laboratory direc-
tor also works with other members of the patient care team to create testing algo-
rithms, design and implement microbial screening protocols, and coordinate public
health reporting. Finally, the laboratory director takes on a myriad of other less-
defined but essential roles and responsibilities, such as representing the laboratory
on institutional committees (eg, antimicrobial stewardship committee, hospital infec-
tion prevention, and control committee), conducting clinically relevant research, and
providing clinical microbiology education to trainees, laboratory staff, and other
members of the health care team.
To qualify as a clinical microbiology laboratory director in the United States, indi-
viduals must fulfill specific educational requirements and have appropriate training
and/or experience.5 Although completion of a clinical microbiology fellowship is
not an absolute requirement for the role, the authors believe that the specialized
training provided by a fellowship is exceedingly beneficial for preparing future labo-
ratory directors for their responsibilities and is highly valued by potential employers.
In this article, the authors discuss the essential components of a clinical microbi-
ology fellowship and share best practices gleaned from their combined 68 years
of operating 2 doctoral-level clinical microbiology fellowships at Mayo Clinic, Minne-
sota. Although the focus is on the training provided in the United States, the general
principles discussed herein are applicable to clinical microbiology laboratory direc-
tor training programs worldwide.
There are 2 types of formal, medical and public health microbiology (MPHM) fellow-
ship programs in the United States. Although each has slightly different requirements,
the training provided and postgraduation qualifications have many similarities. Both
aim to train postdoctoral level graduates to become successful clinical microbiolo-
gists, able to run a clinical or public health microbiology laboratory. Alternatively, grad-
uates may find employment in industry, as scientific or research leaders for the
development of diagnostic assays or equipment, or they may pursue roles in govern-
ment agencies associated with public health (eg, Centers for Disease Control and Pre-
vention [CDC]) or with oversight of diagnostic products or regulation of clinical
laboratories (eg, Food and Drug Administration [FDA], Centers for Medicare and
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Fellowship Training 523
Medicaid Services). The following sections discuss important details of each fellow-
ship pathway.
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524 Pritt et al
To enhance transparency of the fellowship program both within the institution and
externally, development of a program mission statement and supporting aims are
essential, as they define the program’s purpose, scope of training, and the prospec-
tive applicants.
Mission Statement
Simply defined, a mission statement is a “formal summary of the aims and values” of a
particular group.11 They are used by companies and organizations to convey their
overall purpose, identifying the scope, services, intended users, and internal guiding
principles to the interested public. For accredited fellowships, a well-defined mission
statement can be used to succinctly frame the program’s objectives. As an example,
the following mission statement is currently used for both the CPEP- and ACGME-
accredited MPHM fellowship programs at Mayo Clinic:
Program Aims
Stemming from the mission statement, program aims serve the purpose of conveying
how the program will carry out the organization’s mission. They provide a well-defined
framework of the program’s and institution’s expectations and define the intended
learning outcomes, with measurable actions. Examples of currently used aims for
both the CPEP- and ACGME-accredited MPHM programs at Mayo Clinic include:
1. Foster an environment of learning and mentorship that prepares trainees to
contribute to and advance the field of medical and public health microbiology.
a. Activities/Criteria to Advance the Aim:
1. All trainees will publish or submit for publication at least one peer-reviewed
article, review article, or book chapter during their fellowship or within
1 year of graduation from the program.
2. All trainees will participate in diagnostic assay development or an alternative
MPHM-related research project during their fellowship.
2. Provide a clinical and didactic learning environment that supports the educational
needs of all trainees.
a. Activities/Criteria to Advance the Aim:
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Fellowship Training 525
1. The fellowship program will provide at least 200 hours of didactic content
related to MPHM to all trainees.
2. The fellowship program will provide experiences in all specialty areas of clin-
ical microbiology (eg, bacteriology, mycobacteriology, virology, mycology,
parasitology, infectious diseases serology, public health microbiology,
epidemiology, etc.) and in select areas of the Infectious Diseases clinical
practice (eg, antimicrobial stewardship, infection prevention and control,
rotation with infectious diseases services, etc.).
3. Produce future leaders in medical and public health microbiology.
a. Activities/Criteria to Advance the Aim:
1. All trainees will present a poster or oral presentation at least once before
graduation at a regional, national, or international conference.
2. At least half of all program graduates will assume a leadership role (eg, lab-
oratory or associate laboratory director, senior scientist in industry, etc.)
within 5 years of graduation from the fellowship
SCOPE OF TRAINING
Clinical and Analytical Microbiology
At their core, accredited programs are designed to provide in-depth training focused
on pathogen identification strategies and interpretive guidance for acquired results in
all areas of clinical microbiology. These programs also provide trainees the opportu-
nity to practice these learned skills in a supportive and safe environment, through in-
teractions with laboratory directors, laboratory technologists, patient-facing clinicians,
and other trainees. Generally, the training areas include the following:
Bacteriology
Mycobacteriology
Mycology
Virology
Parasitology
Infectious diseases serology
Public health microbiology
Fundamentals of pathogenesis
Infection prevention and control
Laboratory leadership and management (see later discussion)
Laboratory biosafety and biosecurity
Laboratory regularly oversight
Antimicrobial stewardship
The field of MPHM is continually evolving, with optimization of classic techniques
and introduction of novel methods occurring constantly. Given these advancements,
it is essential that accredited programs provide trainees with the opportunity to
engage with as many of the newly emerging diagnostic modalities as possibly, while
continuing to emphasize the “bread and butter” techniques of clinical microbiology.
Education related to the following diagnostic modalities should be included in any
accredited MPHM program:
Specimen collection, collection devices, and transport/storage conditions
Direct-from-specimen or culture stains
Bacterial, mycobacterial, fungal liquid, and solid media culture methods
Common biochemical reactions for microbial identification
Antimicrobial susceptibility testing
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526 Pritt et al
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Fellowship Training 527
from this dedicated course, fellows participate in monthly small group discussions on
microbiology-specific quality management topics, participate in the critical analysis of
laboratory errors/events, and complete a 1 month or longer laboratory directorship
rotation.
LEARNER ASSESSMENT
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528 Pritt et al
Table 1
Education and training resources
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Fellowship Training 529
Table 1
(continued )
Organization Selected Topics Website/Resource
Centers for Medicare and Information related to https://www.cms.gov/
Medicaid Services (CMS) CLIA Regulations-and-
Guidance/Legislation/
CLIA/index?redirect5/
clia/
Clinical Laboratory Access to antimicrobial https://clsi.org/
Standards Institute (CLSI) susceptibility testing and
other diagnostic
microbiology standards
and related education
webinars
Emory Pathology Case-based quiz modules http://www.path.emory.
e-Learning Portal for bacteria, edu/EPeP/microbiology.
mycobacteria, fungi, cfm
parasites, and viruses
Pan American Society for Case-based virology https://www.pascv.org/
Clinical Virology educational content and
webinars
Society for Healthcare Online courses on https://learningce.shea-
Epidemiology of America Antimicrobial online.org/course-
(SHEA) Stewardship, catalog-list
Epidemiology, and
Infection Prevention and
Control topics
University of Adelaide Provides extensive https://mycology.adelaide.
Mycology Online educational content edu.au/
related to fungi,
including descriptions,
antifungal susceptibility
information, and virtual
self-assessments
learning cycle (eg, rotation). Examples of formative assessment practices include ver-
bal feedback (the hallmark of such assessment), discussions, case studies, and low-
stakes quizzes, among others.
Summative assessments are measures of learning and therefore occur at the end of
the learning cycle.12 Examples of summative assessments include final examinations,
papers, and direct observations, among others, and are often characterized by docu-
mentation and written feedback provided to the trainee from the rotation director and/
or program director. Ideally, programs will have a mechanism to provide learners with
feedback using both formative and summative assessments. One such mechanism is
through the use of rubrics, which are assessment tools that can help provide an objec-
tive appraisal using both types of practices. A rubric identifies performance levels or
criteria and the specific performance descriptions and tasks that must be accom-
plished to achieve each level.15 As a result, the assessment process is more objective
and standardized and provides transparency to trainees regarding the assessment
practice.15 The ACGME requires the formation of Clinical Competency Committees,
to biannually evaluate a trainee’s progress through an evaluation of competency-
based milestones.16 The ACGME milestones are a narrative trajectory of performance
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530 Pritt et al
Table 2
Select listing of medical and public health microbiology community social media, listservs, and
blog sites
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Fellowship Training 531
selected for program evaluation can be collected from many sources, including data
linked to trainee assessments (eg, first-time pass rate for board examinations, mile-
stone progression, etc.), assessment of the program curriculum by faculty and
learners, feedback from employer and graduate surveys, and patient safety
events.6,13,14 The ACGME mandates appointment of a Program Evaluation Commit-
tee (PEC) responsible for program oversight via review of the program’s self-
determined goals and progress toward achievement, ongoing program improve-
ment, including the development of new goals, and review of the operating environ-
ment to identify strengths, challenges, opportunities, and threats as they relate to the
program’s mission and aims.6 This Annual Program Evaluation (APE) provides the
opportunity for program leadership to determine the need for actions or changes,
which are the basis for ongoing program improvement. As with the ACGME mile-
stones, a PEC and APE can be adopted by both ACMGE- and CPEP-accredited
programs.
The MPHM fellowship program director serves many roles, ensuring program accred-
itation, delivery of high-quality education, and successful recruitment and graduation
of fellows. Although many of these roles are specifically defined by the fellowship
accrediting bodies, others are “unwritten” but equally important—and sometimes
harder than written requirements! For example, the program director must maintain
morale of the fellows; support open lines of communication among fellows and faculty;
set clear performance expectations; hold fellows and faculty accountable for their ac-
tions; advocate for the fellowship program and trainees; and serve as a clinician,
teacher, researcher, and professional role models.
Entering into an MPHM fellowship is an exciting time, full of opportunities to learn from
experts in the field and to contribute to the constantly evolving diagnostic arena. How-
ever, this can also be a challenging time for trainees, especially for those without prior
exposure to the clinical laboratory or medical field. It is therefore important for fellows
to strive to maintain their physical health and mental well-being for the duration of the
program. Toward that end, programs and program directors should ensure that
trainees have access to educational material, local resources, and support networks,
as necessary.
Beyond bench rotations, reading textbooks and manuals, reviewing case studies,
participating in rounds, and attending relevant institutional meetings, successful fel-
lowships also set trainees up for independent advancement following graduation.
There are multiple avenues that can be pursued to achieve this, many of them
revolving around increasing trainee visibility and recognition in the MPHM community.
Trainee engagement in these areas is strongly encouraged and will be of significant
benefit as they begin to consider postgraduation employment options. Opportunities
to consider participating in during fellowship include, but are not limited to, the
following:
Trainee membership in MPHM-related societies and organizations including, but
not limited to
American Society for Microbiology (ASM)
Pan American Society for Clinical Virology (PASCV)
College of American Pathologists (CAP)
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532 Pritt et al
FUTURE DIRECTIONS
As the field of MPHM continues to evolve, expanding into increasingly advanced diag-
nostic methodologies and responding to needs of clinicians and patients, accredited
programs will likewise have to adapt to the changing educational content needed by
trainees, which will ensure that trainees remain competitive in the job market and more
importantly, that they are successfully postgraduated. Several areas that the authors
foresee MPHM training programs having to enhance their educational content for,
both in didactic and practice formats, include the following:
Point-of-care diagnostic assay oversight
Digital consultation
Outreach
Laboratory consolidation and centralization
Bioinformatics and big data analytics
Direct-to-consumer testing
In conclusion, with diligence, careful planning, strong leadership, and dedicated
faculty, accredited MPHM fellowships can continue to provide trainees with the
necessary education and skillsets to become successful leaders of their own accord.
ACKNOWLEDGMENTS
The authors would like to acknowledge the contributions of the Mayo Clinic education
program coordinator, Ms. Tasha Gilbertson, and the Associate Program Directors of
the Mayo Clinic Clinical Microbiology fellowship programs, Drs. Matthew Binnicker
and Audrey Schuetz.
DISCLOSURE
Dr B.S. Pritt receives an editor’s stipend from the Journal of Clinical Microbiology,
Clinical Microbiology Reviews, and The Manual of Clinical Microbiology, and also re-
ceives royalties from the College of American Pathologists Press. Dr E.S. Theel re-
ceives a stipend from the Clinical Microbiology Newsletter. C.A. Bowler has nothing
to disclose.
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Fellowship Training 533
REFERENCES
1. Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbi-
ology laboratory for diagnosis of infectious diseases: 2018 update by the infec-
tious diseases society of America and the American Society for Microbiology.
Clin Infect Dis 2018;67(6):813–6.
2. Avdic E, Carroll KC. The role of the microbiology laboratory in antimicrobial stew-
ardship programs. Infect Dis Clin North Am 2014;28(2):215–35.
3. Canton R. Role of the microbiology laboratory in infectious disease surveillance,
alert and response. Clin Microbiol Infect 2005;11(Suppl 1):3–8.
4. Thomson RB Jr, Wilson ML, Weinstein MP. The clinical microbiology laboratory di-
rector in the United States hospital setting. J Clin Microbiol 2010;48(10):3465–9.
5. Department of Health and Human Services, Centers for Medicare and Medicaid
Services. Clinical laboratory improvement amendments of 1988; final rule. Fed
Regist. 2003. Subpart M - Personnel for Nonwaived Testing. Available at:
https://www.ecfr.gov/cgi-bin/text-idx?SID51248e3189da5e5f936e55315402bc38b&
node5pt42.5.493&rgn5div5#sp42.5.493.m.
6. Accreditation Council for Graduate Medical Education (ACGME). Pathology.
2020. Available at: https://www.acgme.org/Specialties/Program-Requirements-
and-FAQs-and-Applications/pfcatid/18/Pathology. Accessed February 16, 2020.
7. The American Board of Pathology. Medical microbiology. 2015. Available at: https://
www.abpath.org/index.php/to-become-certified/requirements-for-certification?
id545. Accessed February 16, 2020.
8. American Society for Microbiology. American Board of Medical Microbiology Cer-
tification. 2020. Available at: https://www.asm.org/Certifications/American-Board-
of-Medical-Microbiology. Accessed February 16, 2020.
9. American Society for Microbiology. Fellowships. 2020. Available at: https://www.
asm.org/Fellowships/CPEP. Accessed February 16, 2020.
10. American Society for Microbiology. CPEP essentials: essentials and guidelines of
an accredited postgraduate fellowship program in medical and public health lab-
oratory microbiology. Est. by the Committee on Postgraduate Educational Pro-
grams. 2018. Available at: https://www.asm.org/getattachment/2a162a8b-5b09-
4c02-9088-37020e30b9c9/Essentials-and-Guidelines_Microbiology-2018.pdf?
lang5en-US. Accessed February 16, 2020.
11. Lexico: powered by Oxford. Mission statement. 2020. Available at: https://www.
lexico.com/definition/mission_statement, 2/16/2020. Accessed February 16,
2020.
12. Shumway JM, Harden RM, Association for Medical Education in E. AMEE Guide
No. 25: the assessment of learning outcomes for the competent and reflective
physician. Med Teach 2003;25(6):569–84.
13. Cook DA. Twelve tips for evaluating educational programs. Med Teach 2010;
32(4):296–301.
14. Frye AW, Hemmer PA. Program evaluation models and related theories: AMEE
guide no. 67. Med Teach 2012;34(5):e288–99.
15. Boateng BA, Bass LD, Blaszak RT, et al. The development of a competency-
based assessment rubric to measure resident milestones. J Grad Med Educ
2009;1(1):45–8.
16. Accreditation Council for Graduate Medical Education (ACGME). Milestones.
2020. Available at: https://www.acgme.org/Specialties/Milestones/pfcatid/
36Nikhil/Program%20Requirements%20and%20FAQs%20and%20Applications.
Accessed February 16, 2020.
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