PEDIATRICS Vol. 100 No. 4 October 1997,
p. e2
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
The University of Massachusetts Medical Center Office-based
Continuity Experience: Are We Preparing Pediatrics Residents for
Primary Care Practice?
ABSTRACT
INTRODUCTION
DESCRIPTION OF RESIDENCY PROGRAM
THE SURVEY INSTRUMENT
RESULTS (TABLE 1)
DISCUSSION
FOOTNOTES
ABBREVIATIONS
REFERENCES
Objective. Surveys of residency graduates and employers have suggested that residency programs do not prepare residents well for practice. Since 1988, pediatric residents at the University of Massachusetts have been paired one-on-one with an office-based pediatrician for their 3-year continuity experience. This survey was conducted to determine if graduates of such a program are prepared to enter pediatric practice.
Methodology. Graduates of the program from 1991 through 1995 who entered primary care practice were surveyed about their preparedness for practice. The questionnaire was also sent to the residents' first employers. The 32 questions were directed to overall sense of preparedness, ability to manage the pace of practice, common illnesses, common behavior problems, anticipatory guidance, office management, and subspecialty problems.
Results. Data from all 25 residents who entered practice and the employers of 20 of the 25 residents were obtained and analyzed. Both groups rated overall resident preparedness to be "well-prepared" or "very well-prepared" and gave high scores on working at the pace of practice, diagnosing and treating common illnesses, diagnosing and treating common behavior problems, and providing anticipatory guidance. Areas in which residents were considered to be less well-prepared included anticipatory guidance about nutrition, managing problems by telephone, office management, gynecology, and orthopedics.
Conclusions. The results suggest that continuity experiences in office practices are associated with preparation for the pace and types of visits that occur commonly in primary care practice, abilities which previous surveys of residency alumni and employers have found lacking. Some areas may benefit from a formal curriculum which may be implemented in the office practice, at the medical center, or at both sites. Preceptors may benefit from faculty development and continuing medical education that is directed not only at teaching skills but also at content areas which were not addressed in their own residencies.
Key words: education, medical, graduate, preparedness for practice, internship and residency, pediatrics/education, physicians, evaluation studies, faculty, medical, health maintenance organizations, questionnaires.Throughout the past 20 years, multiple surveys have documented that graduates of pediatrics residency programs have not felt prepared to practice primary care pediatrics.1 Concurrent assessments of the curriculum of residency programs, beginning with the report of the American Academy of Pediatrics (AAP) Task Force on Pediatric Education in 1978, demonstrated that primary care aspects of pediatric practice were given little time and emphasis.2,5,6 Recently, directors of managed care organizations have added their dissatisfaction with the preparedness of graduates of pediatrics residency programs to practice in their settings.7,8
Multiple changes to the traditional residency curriculum have been proposed to address the Resi-dency-Practice Training Mismatch.7 At the University of Massachusetts Medical Center (UMMC), the response included moving the resident continuity experience from hospital clinics to practices. This report describes a survey of UMMC residency graduates and their first employers, to determine resident preparedness for primary care practice.
DESCRIPTION OF RESIDENCY PROGRAM
A questionnaire was mailed to the 37 residents who graduated from the residency between 1991 and 1995 and who completed a minimum of 2 years in the program. Questionnaires were also sent to the first employers of the 25 residents who entered primary care practice.
Table 1.
Means of the Responses of Residents and Their First
Employers to 32 Questions Regarding the Residents' Preparedness for
Primary Care Practice in the First 1 to 2 Months After Graduation From Residency*
Fig. 1.
Overall preparedness of residency graduates for practice: responses of
residences and employees using a 5-point Likert scale. (Literature:
Resident responses from reference 1; employer responses calculated from
reference 7.)
[View Larger Version of this Image (18K GIF file)]
Surveys from all 25 residents who entered primary care practice
were completed and used in the analysis. Of the 25 residents, 12 (48%)
had their continuity site in various offices of an HMO, 6 (24%) had
been in "private practices," and 7 (28%) had been either in the
UMMC practice or at a UMMC-sponsored community site. The distribution
of employment sites differed from this pattern: 7 (28%) practiced in
HMO sites, 13 (52%) in "private practices," and 5 (20%) in other
settings, such as the Indian Health Service and an academic medical
center. Of the 25, 4 stayed in the same office in which they had their
continuity experience. The employers of 20 of the 25 graduates
responded; of the 5 who did not respond, 4 were no longer in the
practice and could not be located (including 3 from the Indian Health
Service), and 1 did not respond despite multiple requests.
The traditional approach to assessing the primary care component of residency programs has been to focus on readily available quantitative measures, such as the number of patients seen or the amount of time spent, rather than on outcomes. Residents assigned to private practices have been reported to see more patients per session than those assigned to hospital clinics or publicly-funded community clinics,15,16 but the significance of the additional experience per se is not clear. Osborn et al15 compared the performance of residents in different types of continuity sites on the American Board of Pediatrics In-Training Examination and the Behavioral Pediatrics Examination. Residents in private offices had equivalent scores on the In-Training Examination and higher scores on the Behavioral Pediatrics Examination than residents at the university clinic or in public clinics, but the process of assignment was by choice rather than random and the amount of time in the various settings differed, precluding a definitive conclusion about the independent effect of the setting or of the number of patients seen.
Overall Preparedness
The UMMC resident response on question 1, "overall sense of preparedness" was a mean of 4.3, or between "well-prepared" and "very well-prepared." This would seem to echo other studies in which graduates express satisfaction with their residency program,1,4,11 but the current survey differs from previous ones in an important way. In previous surveys, all of the graduates were asked to rate their satisfaction with various aspects of their residency experience. In the UMMC survey, the subset of residents who chose to practice primary care pediatrics were asked to rate their preparation for practice. Comparable elements of the questionnaires from previous surveys suggest that preparation for primary care practice was not rated as highly as overall satisfaction with the program. For example, in the most recent survey published, the score given to the quality of preparation in primary pediatric care clinic (noted by the authors to be equivalent to continuity clinic) was 2.86 on a 5-point scale similar to the one used in the University of Massachusetts survey.1Developmental and Behavioral Pediatrics (DBP)/Anticipatory Guidance
The 1978 AAP Task Force Report identified goals for residency curriculum, including increased emphasis on biosocial and developmental problems of children and adolescents. To train pediatricians who are skilled in these areas, the report suggested that residents spend more time in ambulatory experiences, provide continuous care for a group of their own patients, and develop skill in anticipatory guidance, developmental appraisal, screening, and referral.5 Studies assessing progress in the years after the Task Force Report identified that change came very slowly.2,6 Although a 1989 survey similar to the one used by the 1978 Task Force found that graduates after 1984 thought their training was better in DBP and adolescent medicine, 50% of the 1785 member sample still considered their training insufficient in biosocial areas.2Office Management
Residency programs have been criticized for not preparing graduates in practice management issues, particularly those related to managed care. The Council on Graduate Medical Education reports that, despite concern by many physicians about managed care, more than 75% of physicians have at least one managed care contract, and almost 50% are involved with at least one HMO.20 Of the preceptors of UMMC residents, 45% are employed by a staff-model HMO, and the other 55% have more than one managed care contract. Studies of practicing physicians affirm the need for more training in cost-effective care. Graduates from the University of California, San Diego, between 1979 to 1988 reported that their lowest perceived comfort level was in "economics of pediatric practice."3 Cantor et al11 found that 81% of physicians were satisfied overall with their training, but only 46% rated training in "cost-effective medical care" as excellent or good, and only 4% thought they were prepared for "management aspects of your practice." Studies of internal medicine residents and family physicians report similar results.21,22Subspecialty Areas
For primary care pediatricians to be the initial managers of subspecialty problems, they need a firm basis in subspecialty areas.23 Regarding "office management of subspecialty areas," residents felt least prepared in gynecology (2.7) and orthopedics (3.0). Women graduates gave slightly higher scores in gynecology than men, but both genders reported feeling less than "fairly well-prepared" (women 2.8, men 2.5). Gynecology and orthopedics have been identified as weaknesses in previous surveys. In the 1978 AAP Task Force Report, 66.9% of practicing physicians surveyed reported a low feeling of competence when dealing with gynecology, and 73.9% said they had insufficient training in that area.5 In the same survey, 55.9% of physicians reported a low feeling of competence when dealing with orthopedics, with 60% reporting insufficient training; a recent study also identified orthopedics as an area of weakness.3Limitations of This Study
Because there was not a uniform period of time in the present study from completion of residency to the time of the survey, it is possible that graduates with a longer period may not have rated their preparation the same as those with a shorter period. The direction of possible bias is hard to predict: perhaps those in practice for a few years have a better idea of what they did not know at first and, therefore, rate their preparation lower; or those in practice for only a few months might still feel anxious and, therefore, rate their preparation lower. In fact, the variation from year to year was slight, with the means of overall preparation for the five cohorts being 4.3, 4.3, 4.3, 4.2, and 4.2.Implications
- The most important finding of the survey is that both the residency program graduates feel prepared and their employers rate the graduates as well-prepared to very well-prepared for practice. After 3 years in the office setting for their continuity experience, the residents feel prepared for the pace of practice and the evaluation and management of the types of visits that occur commonly in office practice.
- One notable difference between the results of this survey and the 1978 AAP Task Force Report and related studies was in preparedness to evaluate and manage developmental and behavioral issues and to provide anticipatory guidance. The relatively high ratings may relate to the combined teaching approach taken in the residency program, utilizing both medical center faculty and community practitioners, a strategy that may be useful in other areas as well.
- The survey demonstrates that practice management education does not happen by osmosis; physical presence in the practices is insufficient to assure recognition of the structure of the practice or management issues such as the use of the telephone. A more formal process, including curriculum, is required.
- Preceptors, who may themselves be graduates of programs that gave little attention to areas such as orthopedics and gynecology, may have difficulty teaching in those areas without assistance. Faculty development and continuing medical education programs directed in these areas may result in increased teaching abilities and expanded clinical abilities.
Conclusions
Three years of primary care continuity experience in an office practice is associated with a high level of resident preparedness for practice, as determined by the graduates and their employers. Foci of relative weakness remain, however; practice management and certain subspecialty areas, which need to be addressed explicitly, either by combining office-based training with medical center programs or by developing curricula for practitioner-preceptors. Preceptors may themselves benefit from continuing medical education in the same areas.* From the Department of Pediatrics, University of Massachusetts Medical Center, Worcester, Massachusetts.
Dr Roberts is currently at Moses Cone Health System, Greensboro, North Carolina.
Dr DeWitt is currently at Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Reprints not available.
Received for publication Feb 27, 1997; accepted May 13, 1997.
Address correspondence to Kenneth B. Roberts, MD, Pediatric Teaching Program, Moses Cone Health System, 1200 North Elm Street, Greensboro, NC 27401.
AAP, American Academy of Pediatrics. UMMC, University of Massachusetts Medical Center. HMO, health maintenance organization. DBP, developmental and behavioral pediatrics.
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Pediatrics (ISSN 0031 4005). Copyright ©1997 by the American Academy of Pediatrics
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