Creating a Lifestyle Medicine Specialist Fellowship: A Replicable and Sustainable Model

Abstract

As new specialties emerge in medicine, certification pathways must be defined and formalized. The Lifestyle Medicine Physician certification, including both experiential and educational pathways, have been in place for several years. Although raising competence across all specialties through the Lifestyle Medicine Physician Diplomates to a foundational level is essential, additional expertise must be attained to be a true Lifestyle Medicine Specialist as outlined by the American Board of Lifestyle Medicine. This column will describe how Loma Linda University Health (LLUH) created a Lifestyle Medicine Specialist Fellowship that meets the educational pathway requirements for the Lifestyle Medicine Specialist certification and how it can be replicated and sustained at other training sites across the nation.

As new specialties emerge in medicine, certification pathways must be defined and formalized, both through educational and experiential pathways.

In 2018, the AAMC (Association of American Medical Colleges) medical news section recognized lifestyle medicine (LM) as an emerging specialty and highlighted the exploding interest in this field.¹ As new specialties emerge in medicine, certification pathways must be defined and formalized, both through educational and experiential pathways. The American Board of Lifestyle Medicine (ABLM) created an inaugural exam in 2017 for physicians who are certified by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association to demonstrate a foundational level of competence in LM. These Diplomates of ABLM carry the title Lifestyle Medicine Physician and qualify for certification based on the Experiential Pathway. Shortly thereafter, an Educational Pathway emerged for the Lifestyle Medicine Physician through the Lifestyle Medicine Residency Curriculum (LMRC) (see Table 1). Although raising foundational level competence across all specialties through the Lifestyle Medicine Physician Diplomates is essential, additional expertise must be attained to be a true LM specialist as outlined by the ABLM. Subsequently, Kelly and Shull² argued that an LM specialist must be trained in a clinical setting where they optimally dose LM interventions for rapid disease reversal and develop first-hand understanding of the evidence base supporting the LM approach. This column will describe how Loma Linda University Health (LLUH) created a LM Specialist Fellowship that meets the Educational Pathway requirements for the LM Specialist certification and how it can be replicated and sustained at other training sites across the nation (see Table 1).

Table 1.

ABLM Certification Pathways With Descriptions.

ABLM Certifications	Pathways to Certification	Requirements
LM Physician	Experiential	Certified ABMS Physician × 2 years Complete 30 hours online CME and 10 hours in-person CME 1 LM-related case study showing disease reversal Successful exam completion
	Educational	LMRC completion during residency training Successful exam completion
LM Specialist	Experiential	Certified LM Physician 720 LM clinical hours 300 LM scholarly activity hours
	Educational	LM Specialist Fellowship (concurrent LM physician educational pathway included)—LLUH first approved program Preventive and Lifestyle Medicine Specialist residency program—in development at LLUH (not discussed in this column)

Abbreviations: ABLM, American Board of Lifestyle Medicine; ABMS, Amercan Board of Medical Specialties; CME, continuing medical education; LLUH, Loma Linda University Health; LMRC, Lifestyle Medicine Residency Curriculum.

Loma Linda University Health Background

LLUH has a historical background in LM and the faith-based approach of this medical community includes an emphasis on personal wellness and aligns with becoming one of the first Blue Zones and the only original Blue Zone in the United States.³ In addition, the Adventist Health Studies at LLUH have explored the links between nutrition and disease among Adventist for over 40 years.⁴ This LLUH background provided fertile ground for development of clinical and educational LM programs. Several of these parallel efforts have taken shape over the past few years, including (a) development of the LMRC in collaboration with American College of Lifestyle Medicine (ACLM), which enables residency graduates to become LM Physician Diplomates through an Educational Pathway (Table 1) and (b) implementation of inpatient and outpatient LM service lines for patient care experiences.^5-7 As the national demand and interest in the emerging field of LM grew, the LLUH background and recent innovations led to unsolicited requests for higher level training, thus prompting the creation of a 12-month LM Specialist Fellowship as an Educational Pathway to this advanced level certification.

LM Specialist Fellowship Infrastructure

Our goal for the LM Specialist Fellowship was to create a training program that would meet the developing requirements for LM Specialists, including components proposed by Kelly and Shull, the ABLM and the LM Intensivist competencies as outlined by Kelly et al.^2,8,9 Through conversations with national leadership in the ACLM and the ABLM, we designed a program that would be ABMS aligned and facilitate eventual American College of Graduate Medical Education (ACGME) accreditation of the 12-month fellowship. We utilized the ACGME Common Program Requirements (Fellowship) document as a framework and leveraged our resources that included a pool of faculty with expertise in LM, growing inpatient and outpatient LM consultation service lines, ongoing scholarly activity in LM, a robust GME program with potential internal candidates, and the opportunity for fellows to interact with other trainees (students and residents).¹⁰ Creating a sustainable financial model for the fellowship and determining opportunities for intensive therapeutic lifestyle change (ITLC) training were our two biggest barriers to the LM Specialist Fellowship implementation.

Funding was the largest practical challenge. Expenses included in our proforma were PGY-4 level fellow salary/benefits and external training at an ITLC. Program director (PD) and administrative time was an added expense, but we did not include this because our PD and faculty agreed to donate administrative time for the first year of the fellowship. There are institutional funding mechanisms for ACGME accredited fellowships, but these were not available to us as an emerging LM Specialist Fellowship. Instead, we proposed a model where the fellow is hired as a junior faculty for 12 months. They work on campus in their primary specialty for 30% to 40% of the time (revenue generating) for 11 out of 12 months, freeing the remaining 60% to 70% of the time to train in LM clinical and scholarly activities. This approach has an advantage of keeping clinical skills sharp in their primary area of training while gaining the LM Specialist skills and knowledge. We arranged for our fellows to spend a month participating and learning the clinical approach to disease reversal at an ITLC program which created added tuition expense for the ITLC in addition to no revenue generation during that month. Over time we determined that it worked best to have the ITLC month occur as close to the beginning of the fellowship as possible as it provides an excellent orientation and quickly raises the fellows level of competence in LM, thus preparing them to practice more independently in the inpatient and outpatient settings at our institution.

Practically speaking, the LM Specialist criteria as outlined by the ABLM requires 720 LM clinical hours and 300 hours of LM-related scholarly activity. The clinical time includes 120 hours of ITLC programming, 60 hours of group facilitation, and 120 hours of individual LM patient interactions. In addition, the LM Specialist requires documentation of 12 case studies demonstrating disease reversal while covering a 6-month time frame with at least 3 points of contact per case. When considering all these requirements totaling 1020 hours, the minimum length of the fellowship is 6 months full time or 12 months half time. Our LM Specialist Fellow time allocation for the 11 out of the 12 months when on campus generally follows this plan: 40% revenue generation in their primary specialty, 40% LM clinical activities and 20% LM scholarly activity time. Table 2 provides a sample weekly fellow schedule.

Table 2.

Sample Lifestyle Medicine (LM) Specialist Fellowship Weekly Schedule.

	Monday	Tuesday	Wednesday	Thursday	Friday
Morning	Revenue generation	Revenue generation	LM outpatient clinic	LM inpatient service	LM scholarly activity
Afternoon	Revenue generation	Revenue generation	LM inpatient service + group	LM inpatient service + group	LM scholarly activity

Based on the unsolicited requests for training and our internal pipeline, we suspected there would be sufficient interest in a fellowship program to train 1 to 2 applicants per year. We limited our program to 1 fellow for the first year due to the administrative load required to create a new program and lack of dedicated faculty time for these activities. In our first 3 years, our fellows had 3 different primary specialties for revenue generation: Preventive Medicine (the home LM fellowship department), Family Medicine, and Emergency Medicine. Compensation differentials exist between these specialties as well as sites within the specialties and this has affected the amount of time fellows need to spend in their revenue generating activities to cover expenses. We were able to begin providing a small amount of funded administrative time for the PD in the second year of the program, utilizing some of the revenue generated during the LM clinical activities to offset this expense.

Lessons Learned

In the first 3 years of the program, we have learned many lessons, both positive experiences along with a few challenges. Each of our fellows has remained and worked as a faculty member after completing the fellowship. They are also national leaders: connecting, speaking and elevating prevention and lifestyle, representing us outside of our institution. However, when negotiating with other departments to create revenue generating time, we encountered strong hesitancy to empanel physicians as primary care providers during the 12-month fellowship. Instead we realized hospitalist, urgent care, student health, preprocedure, and coverage work to be preferable. We also found that revenue generating shiftwork was a challenge if it involved overnight schedules. We had to turn away one qualified candidate because there was insufficient demand in the primary specialty to create revenue for their fellow salary. This is a challenge we will continue to encounter as long as we use this financial model or until there is sufficient LM-related clinical activities to generate revenue.

The 3 fellows who have trained with us have created significant value for our institution from both a clinical and educational perspective. They have helped lead in our LMRC project and trained our residents and medical students in LM. We have provided them with a concentrated opportunity to develop competence in treating and reversing chronic disease with a spectrum of appropriate LM dosing in the ITLC, inpatient and outpatient settings. The ABLM has had an Experiential Pathway for LM Specialist certification in place for the past year and we are pleased to report that our PD and first fellowship graduate are 2 of the 4 first LM Specialists approved through this pathway. In addition, the LLUH LM Specialist Fellowship, is the first Educational Pathway to be approved by the ABLM for LM Specialists. Over the next 3 to 5 years, the ABLM hopes to encourage 30 residency and/or fellowship training programs to create similar Educational Pathways for the LM Specialist certification in order to facilitate ABMS recognition of the field of LM and to create ACGME support for such programs. Last, we believe the LM Specialist Fellowship model implemented at LLUH is replicable and sustainable, thus enabling additional sites to more easily implement similar LM Specialist Fellowship programs in the future.