1804 - Subspecialty Practice Pathway Closure as an Inflection Point in Fellowship-Trained Leadership: An Analysis of the Spinal Cord Injury Medicine Subspecialty

Objectives: Creation of a new subspecialty board by the American Board of Medical Specialties signals a specialty's authority and expertise over a defined area of medicine. Early in this process, most specialty boards offer a limited practice pathway, allowing experienced clinicians to certify without completion of fellowship training. Once this practice pathway is closed, fellowship-trained physicians are expected to increase their proportionality within that field. Our objective with this study was to determine if subspecialty leadership also follows this trend, and to determine if closure of the practice pathway accelerates this trend. We used Spinal Cord Injury Medicine (SCIM) as our use case as it is the longest tenured subspecialty within PM&R.

Design: Cross-sectional study of publicly available fellowship directories and program webpages across multiple academic years. Fellowship directors were identified and classified by training pathway. An interrupted time series (ITS) analysis was performed to assess the association between practice pathway closure and the proportion of fellowship-trained program directors. In addition, we noted the current state of fellowship director training backgrounds in the other primary PM&R subspecialties.

Results: Across 27 academic years, the proportion of SCIM program directs who completed fellowship themselves increased dramatically (0% in 1998 to 84.6% in 2025). Furthermore, ITS analysis demonstrated a significant increase in the proportional trend of fellowship-trained program directors following closure of the practice pathway (2007). At the start of the 2025-2026 academic year, fellowship-trained program directors represented: Pain Medicine 64%, Sports Medicine 100%, Pediatric Rehabilitation Medicine 96%, and Brain Injury Medicine 68%.

Conclusions: Leadership in PM&R subspecialties such as SCIM is increasingly represented by fellowship-trained fellowship program directors. Closure of the certification practice pathways appears to accelerate the transition toward fellowship-trained leadership. Board certification policies thus not only shape the membership of a field, but also its leadership pipeline, with implications for education and workforce development.