Pediatric Resident Education Research Articles

Pediatric residency education.

On February 1, 1997, new pediatric Residency Review Committee guidelines became effective. Eighteen months later, pediatric residency program directors were queried regarding the implementation of these guidelines. Because both the challenge to implement these guidelines and the opportunities to shape pediatric graduate medical education rest with the program directors, obtaining the feedback and suggestions from this group is seen as the keystone of future planning endeavors. A 20-question multiple-choice/opened-ended questionnaire was sent to the 201 members of the Association of Pediatric Program Directors in 2 mailings in August and September 1998. A final response rate of 70% was achieved. Very few program directors reported difficulties in instituting the new residency review committee requirements. The exceptions to this pattern were those requirements pertaining to limitations on time spent in intensive care experience and in the neonatal intensive care unit, wherein 34% of the respondents identified barriers. Although the majority of respondents regarded these requirements as very good or sufficient, some program directors expressed concern regarding insufficient amounts of time available for preparation in intensive care (18%), neonatal intensive care unit (22%), behavioral/developmental pediatrics (16%), and in adolescent medicine (13%). In general, programs have been more successful in defining new competencies than in developing curricula to teach them. The majority of respondents also indicated that their residents' exposure was excellent or satisfactory in all 6 of the following practice settings: private office-based practice for continuity clinic, private office-based practice for outpatient rotation, predominately managed care practice, community clinics for continuity clinic, community clinics for outpatient rotation, and hospital-based practice for continuity clinic. They also indicated that they had no serious concerns about the types of career development assistance offered to residents and the types of follow-up tracking of residents. The findings from this survey have reaffirmed the merit of the current system of pediatric residency education. They have also revealed the commitment of program directors to address the complex issues generated by the evolution of health care delivery, and thereby contribute to the optimal provision of pediatric health care now and in the future.

Let's Go Shopping: A Tool for Pediatric Resident Education

Residency training is designed to allow trainees to develop the clinical skills and the knowledge base necessary to practice their specialty independently.1 Most pediatric residency programs have been hospital-based, usually in tertiary care institutions. Even required primary care continuity experiences are often based within urban hospital clinics. As a result, pediatric residency graduates have good preparation to care for critically ill children or children with special needs, but may be less prepared to care for generally healthy children or to answer the practical questions that will comprise the bulk of a primary care pediatrician's practice. In fact, many pediatric residents complete training without exposure to many of the practical aspects of primary care and community pediatrics.2–4 It is difficult to teach residents many key aspects of community and ambulatory pediatrics effectively. Certain issues and skills require active, hands-on involvement. Participatory teaching formats have equal or more efficacy than traditional didactic lectures in many instances and are well-received by the learners.5–7 The participatory format particularly enhances practical skill and knowledge acquisition. There are many practical aspects of primary care and community pediatrics that cannot be taught in a lecture and might be more appropriately taught through hands-on involvement. Many of these involve issues dealt with regularly by parents, such as administering unpleasant tasting medication. Physicians may be unaware that such an issue can create an obstacle for parents. Another issue for parents, especially new or inexperienced parents, relates to the purchase of items needed for routine care of healthy infants (such as car seats and formulas) or items to help with minor acute illness (such as thermometers and humidifiers). Parents who receive little guidance in item selection can find this a perplexing and frustrating experience. Families who are financially disadvantaged or who live in an underserved …

Pediatric Residency Training and the Needs of Gay, Lesbian, and Bisexual Youth

Objective: This study surveys the education of pediatric residents about the needs of gay, lesbian, and bisexual (GLB) youth. The report measures the extent to which such training is considered valuable by those responsible for its administration and it evaluates the awareness of community referrals for GLB youth. Methodology: U.S. pediatric residency directors and chief residents were surveyed using a questionnaire designed by the authors. Percentage tabulation of the questions was performed. Chi-square analysis of two questions was done to determine if there was an association between the responses given and whether or not a respondent was from a program that offered training to their residents. Results: Over half of the respondents indicated that their programs offered training in the care of GLB youth. This increased to over three fourths when those respondents who indicated that their program was planning such training efforts were included. There was a broad distribution in the form and prevalence of training techniques. Over 90% of the respondents indicated that they valued the inclusion of GLB youth issues into residency curricula. A lesser majority indicated an awareness of community referrals for GLB youth. Conclusions: A large majority of pediatric residencies are either training their residents about the needs of GLB youth or are developing such training opportunities. The form and extent of the training varies widely. As such, the continued development of educational approaches and evaluation measures are encouraged.

Radiologic education of pediatric residents during morning report.

The authors assessed the radiologic educational content of a pediatric morning report teaching conference to determine ways of improving radiologic education of pediatric residents. The authors conducted a prospective, observational study from September 1995 to June 1996. Data collected from conference case presentations included types of radiologic studies shown and unanswered radiologic questions. During 388 case presentations, 559 radiologic studies were shown. Imaging modalities most commonly shown were plain radiography, computed tomography (CT), and ultrasound. The most common types of images shown were chest and abdominal plain radiographs and head CT scans. Common unanswered questions concerned radiologic study indications and techniques and radiologic appearance of diseases. Pediatric residents must learn basic radiologic interpretation methods, imaging approaches to common problems, and ways of using the radiologist as a consultant. A large part of their radiologic education occurs in morning report, from nonradiologists. Participating in a morning report is an important way for radiologists to enhance the education of primary care residents.

An ethics curriculum for the pediatric residency program. Confronting barriers to implementation.

The 1997 Residency Review Committee requirements in pediatrics mandate a structured curriculum in medical ethics for all accredited pediatric residency programs. To our knowledge, there are no published models for the development of an ethics curriculum for pediatric residents. Several obstacles may confront those attempting to begin an ethics teaching program. To describe the successful implementation of a structured ethics curriculum for pediatric residents. Our program was designed to overcome the following obstacles: (1) time constraints of faculty and residents, (2) scheduling difficulties and lack of continuity, (3) attitudes of residents toward the material, and (4) inadequate ethics training among faculty. In addition to traditional topics in medical ethics, the curriculum focuses on issues that confront residents primarily during their training, issues that may shape their professional values in important ways. This ethics curriculum has been successfully implemented in our own program and offers solutions to common barriers faced by those seeking to implement an ethics curriculum for pediatric residents. We present the ethics curriculum currently in use at our institution as a tool that may be adopted as it stands or as altered by others as they develop their own program's ethics curriculum. We believe the proposed curriculum directly confronts many of the barriers to successful ethics education of pediatric residents.

COMPUTERIZED INTERACTIVE MULTIMEDIA PROGRAMS AS TEACHING TOOLS IN PEDIATRICS. 1773

The change in focus of pediatric resident education to ambulatory primary care has decreased the contact time for inpatient experience. Rapid developments in computer technology provide us with the capability to combine sights and sounds of interactive multimedia programs to supplement the pediatric learning experience.

An analysis of the operative experience of North American pediatric surgical training programs and residents

There has been a rapid increase in the number of pediatric surgical training programs. To meet the goals of quality patient care and surgical education, training and practice activities must be objectively monitored. The aim of this study was to collect and analyze the experience of American and Canadian Pediatric Surgical training centers and residents. The authors collected the 1-year operative experience of 31 American and six Canadian training programs and the 2-year operative experience of the 25 most recently graduated residents. Categories analyzed included total cases, defined categories (neonatal, important, and tumor cases), routine cases, thoracic, cardiac, urologic reconstructive, head and neck, endoscopy, vascular, plastics and burn procedures. From these data six assumptions about the training in pediatric surgery were addressed. (1) The operative activity of the United States and Canadian training programs and residents are comparable. The results show that there are few major differences in operative experience. (2) There should be variability in operative experience between programs but little variability between residents. The North American operative experience for both residents and institutions are marked by high variability and leftward shift in the frequency distributions. (3) A resident's training should consist of a significant portion of “index cases” and fewer routine cases. The residents perform 28% of their total cases in the three defined categories (index cases) and 26% as routine cases. (4) Pediatric surgeons are the true general surgeons, performing operations in areas such as cardiac, reconstructive genitourinary, plastic, and burn surgery. Examination of the data shows that most programs and residents perform few cases in these four areas. (5) Certain procedures such as thoracic, genitourinary, vascular, head and neck, and endoscopy remain within the domain of pediatric surgery. The results show that this assumption is true for thoracic, vascular, head and neck, and endoscopy but not for genitourinary, and there is wide variability between institutions and between residents. (6) “Core” pediatric surgical conditions such as esophageal atresia, biliary atresia, and intersex are still available in significant numbers to train residents. The data show that a surprising number of programs and residents perform few or none of the core operations. This analysis is the first step toward monitoring of pediatric surgical resident education. A future study is underway to evaluate the current experience of practicing pediatric surgeons who have taken the recertification examination.

Pediatric Resident Education in Community Settings: Reports From Workshops

These reports are organized into two sections. The first section consists of general recommendations that were common to most of the workshops; the second section reports workshop-specific recommendations. In the editing process, we have attempted to consolidate and report the important points and recommendations of the workshops, realizing that some omissions may occur and that full agreement was not reached on all recommendations. GENERAL RECOMMENDATIONS Recommendation The residency director and/or chairperson should initiate a formal planning and implementation process. Action Steps 1. Appoint an individual as director of community-based education. 2. Garner support from the department, hospital, community, and other organizations, such as the American Academy of Pediatrics (AAP), for the program and the director. 3. Establish a community education planning and steering committee that includes key individuals for the program, such as: • The department chairperson and hospital administrator; • Academic faculty, particularly divisions of general, adolescent, and developmental medicine, and residents; • Outside community pediatricians, such as those involved in the Community Access to Child Health (CATCH) program, leaders of school health programs, community agencies, and medical directors and administration staff of managed care organizations; • Parents, especially those of children with special needs. Recommendation The program director and committee should become familiar with other programs and assess local needs. Action Steps 1. Review written documents such as the program requirements of the Resident Review Committee, the Ambulatory Pediatrics Association's residency training guidelines, and Pediatric Education in Community Settings, A Manual1 2. Contact and visit existing community-based programs for residents.

Financing Pediatric Education in Community Settings

Increasingly, hospital-based pediatric outpatient departments are recognized as settings that attempt to combine two critical, but not always compatible, mandates: (1) education of medical students and pediatric residents in outpatient pediatrics, and (2) service, often with inadequate resources, to a socially highrisk population with a disproportionately high prevalence of social, family, and psychological dysfunction. Coexistence of these two mandates has raised a number of concerns, because pediatric ambulatory care education and training have historically been based almost exclusively in a hospital setting. Trainees often get a false impression of the types of problems they will be dealing with in pediatric primary care and of how an efficient pediatric practice is managed. In addition, they often are supervised by full-time faculty who have little if any experience in community settings and who practice only part time or not at all. These problems have led to a widespread desire to train pediatric residents outside the hospital, in settings that more closely approximate the places in which they will practice in the future. Residency programs that address this issue also provide residents with the opportunity to be trained by seasoned practitioners whose primary professional responsibility is the outpatient care of children. To date, little has been written about the cost or the financing of such educational efforts. This article summarizes what is known about the costs. We also attempt to specify the costs that should be anticipated for the various components and steps involved in devising and implementing pediatric community-based educational programs and to describe potential sources of funding for such programs.

Recruiting Community Faculty

The success of community-based resident education depends on a partnership between a residency program and a variety of individuals, physician and nonphysician, in the community. The process of recruiting community faculty in the education of pediatric residents begins with selection of learning objectives. Next, characteristics of effective teachers and teaching sites should be listed so that appropriate faculty may be identified and recruited. A residency program's existing physician network of both referring physicians and graduates of the residency is a good beginning point for making contacts. Selection of specific educational goals, objectives, and activities will lead to identification of potential nonphysician participants. Understanding why community colleagues might want to become part of the training program leads to techniques for contacting and recruiting them.

Faculty Development for Community Practitioners

Developing the academic skills of the individuals who will serve as educators and role models in the community is critical to pediatric resident education in community settings. The main focus of any faculty development program must be on teaching, although for a subset of individuals, the development of research skills should also be a consideration. The three key elements that must be considered for an effective faculty development program include: (1) creating a culture of mutual respect between full-time and community faculty; (2) basing the program on sound principles of education theory, especially adult learning theory, using appropriately trained faculty; and (3) establishing ongoing institutional financial and philosophical support. Effectively addressing these elements should create a faculty development program that will help the community practitioner become an effective role model and practitioner- preceptor-educator.

STATEMENT OF PEDIATRIC FELLOWSHIP TRAINING

In 1990, the Federation of Pediatric Organizations adopted a statement on pediatric fellowship training.1 This revised statement represents the current position of the federation regarding the purpose and objectives of fellowship training. The federation continues to support the concept that "the principal goal of fellowship training should be the development of future academic pediatricians." Within academic and teaching centers, there is a need for master clinicians, skilled teachers, and productive investigators who conduct research with varied interests. Graduates of pediatric fellowship programs should be proficient in both direct and consultative clinical care, teaching, and a selected area of research. Thereafter, differentiation of interests and activities should be expected and encouraged, but graduates of the fellowship programs in all settings should continue their involvement in research, whether collaborative or direct, to add to the body of knowledge in their area of interest. The following guidelines for fellowships are recommended: 1. Fellowship training should prepare pediatricians to care for children with complex problems within their areas of special expertise and to serve as consultants. Fellows should participate directly in the care of patients and should serve as consultants, with guidance and supervision provided by senior clinical mentors. 2. Fellowship training should include the development of skills as an educator, including presentation skills, curriculum development, and evaluation. Fellows should participate in the education of pediatric residents and the continuing education of practicing pediatricians. 3. Each fellow should have a mutually agreed on research mentor(s). It is essential for the fellow to have mentor(s) capable of fostering the trainee's career development.

Question-and-Answer Session

Presentations at the symposium "Pediatric Practice: How to Survive and Thrive in the Changing Health Care System" originated from a concern about how pediatricians will practice in the coming century. The papers published in this supplement describe the changes pediatricians likely will see in the coming years. Changing health needs will require adaptations in the education of pediatric residents and medical practice. Involvement in community-health activities will become more important. Managed-care systems will impose new demands on practicing physicians. Adapting to these changes, without compromising quality of care, will be a challenge to those who provide children's primary health care. As pediatricians and other children's advocates meet the demands on the business side of pediatrics, it must not be forgotten that every child has the right to a quality "medical home" that has a foundation built on a trusting therapeutic relationship between patients and their pediatricians.

Use of the electrocardiogram in a pediatric emergency department.

To ascertain the quality of electrocardiogram (ECG) use in a pediatric emergency department (PED). Patient series. Pediatric emergency department in a university-based hospital. Seventy patients, aged 2 months to 22 years. All ECGs obtained in the PED were received by the Division of Pediatric Cardiology during the 15-month study period. The charts of all patients were then reviewed to determine the (1) indications for obtaining an ECG; (2) accuracy of documentation; (3) impact of ECG results on the treatment of patients; and (4) concordance between PED and pediatric cardiologists in ECG interpretation. Chest pain was the most commonly documented indication, accounting for 54% of the ECGs obtained. Other indications were suspected arrhythmias (11%), seizure and syncope (11%), drug exposure (8%), and miscellaneous (16%). Twelve charts (17%) lacked documentation of ECG results. Ten ECGs (14%) were performed improperly. Twenty three (32%) were interpreted differently by the pediatric cardiologists; 14 ECGs (20%) had potential clinical relevance. Thirty-seven (52%) ECGs were useful in patient care; this was significantly associated with the presence of a PED attending (P = .03 by Fisher's Exact Test). We recommend education of pediatric residents in ECG interpretation and subsequent review by a pediatric cardiologist of each ECG performed in the PED.

The physician and Down syndrome: are attitudes changing?

A survey of attitudes of pediatricians, child neurologists, and pediatric surgeons toward Down syndrome is compared with a similar study reported in 1975. A contemporary physician would be much more aggressive in treating a child with Down syndrome who has associated anomalies such as duodenal atresia or congenital heart disease. Few would recommend institutionalization of a person with Down syndrome; the majority expect that such individuals could productively spend their adult lives in group homes. Positive changes in physicians' attitudes during the past 15 years have been influenced by parent advocacy groups, court decisions, and studies showing that the ultimate intellectual and social skills of Down syndrome children are greater than was previously believed. The most prominent variable associated with attitudes was the physician's age: the older the physician, the more likely he or she would be nonsupportive of active treatment on behalf of the Down syndrome individual. These findings suggest that ongoing education of medical students and pediatric residents in the field of developmental disabilities and bioethics is required in order to promote well-informed advocacy for the mentally handicapped.

Statement on Pediatric Fellowship Training

The following statement was adopted by the Federation of Pediatric Organizations in February, 1990. The Federation consists of the following pediatric organizations: Ambulatory Pediatric Association, American Academy of Pediatrics, American Board of Pediatrics, American Pediatric Society, Association of Medical School Pediatric Department Chairmen, Association of Pediatric Program Directors, Society for Pediatric Research. The Federation supports the concept that "the principal goal of fellowship training should be the development of future academic pediatricians." Graduates of pediatric fellowship programs usually work in academic centers with significant time set aside for research. Some fellowship-trained pediatricians, particularly neonatologists, allergists, and neurologists, may not work in hospitals or ambulatory settings that are associated closely with academic programs. Fellowship-trained pediatricians in all settings should be encouraged to continue their interest in research to add to the body of pediatric knowledge. To achieve the goal of training pediatric scientists, the following guidelines for fellowship education are recommended: 1. Upon completion of a pediatric fellowship, the trainee should be proficient in clinical care, teaching, and research. Fellowship training should prepare a pediatrician to care for children with complex illnesses within his/her area of special expertise and to serve as a consultant for the general pediatrician. In addition, the fellowship-trained pediatrician should be responsible for the education of pediatric residents and the continuing education of practicing pediatricians. For this reason, fellowship training should include interpersonal skills and pedagogical techniques. 2. Research training should begin as soon as possible; premedical students, medical students, and pediatric residents should be encouraged strongly to participate in meaningful research, and research activities should be carried out throughout fellowship training.

Teaching Developmental Pediatrics to Pediatric Residents: Effectiveness of a Structured Curriculum

A national Task Force on Developmental Pediatrics was convened in 1979 to produce a curriculum for pediatric residents pertaining to the detection, assessment, and management of children with atypical development. During a 2-year period, the task force developed a structured curriculum composed of specific goals, educational objectives, and matched learning activities that identified and described the basic knowledge, skills, and attitudes of developmental pediatrics to be acquired during a pediatric residency. Subsequently, the curriculum was implemented and evaluated in 11 pediatric programs with a developmental pediatrics rotation. On a seven-point subjective scale, the mean resident (n = 64) rating of the curriculum's usefulness was 6.0 and of their perceived competence in the skills of developmental pediatrics was 5.2; the mean percent of this competence attributed to the curriculum-based rotation was 56.6. On an objective case management test, residents who used the curriculum scored significantly (P less than .005) higher than those who did not. These results suggest the efficacy of structured curricula in pediatric resident education.

Internal medicine and pediatric residency education for primary.

Internal medicine and pediatric residency education for primary.