PEDIATRICS Vol. 106 No. 2 August 2000, pp. 323-329

REVIEW ARTICLE:
Pediatric Residency Education

Holly J. Mulvey, MA^*, Ethan A. B. Ogle-Jewett, MA^*, Tina L. Cheng, MD, MPH, and Robert L. Johnson, MD^§

From the ^* Future of Pediatric Education II (FOPE II) Project, American Academy of Pediatrics, Elk Grove Village, Illinois;  Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine and Public Health, Washington, DC; and ^§ Department of Pediatrics, New Jersey Medical School, Newark, New Jersey.

	ABSTRACT

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Objective.  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.

Methods.  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.

Results.  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.

Conclusion.  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.  Key words:  graduate medical education, curricula, residency programs, competencies, residency review committee.

The pediatric Residency Review Committee (RRC) of the Accreditation Council on Graduate Medical Education is charged with the responsibility of ensuring that pediatric residency education^a will prepare pediatricians to meet the current and future needs of infants, children, adolescents, and young adults. New guidelines from the RRC^b became effective on February 1, 1997. Because both the challenge to implement these guidelines and the opportunities to shape pediatric graduate medical education rest with the program directors, obtaining feedback and suggestions from this group is seen as an important element in assessing the impact of the new requirements.

This article describes the results of a survey designed to garner insights of program directors on issues ranging from the RRC requirements in clinical and practice settings to the acquisition of other mandated competencies to issues pertaining to career development. This study was initiated by the Education of the Pediatrician Workgroup, a component of the Future of Pediatric Education II Project. As part of the Project, key leaders in the pediatric community addressed the education of pediatricians and the provision of pediatric care into the next millennium. Key findings, such as those discussed below, will illuminate the current residency education situation and reveal implications for future pediatric residency education.

	METHODS

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Eighteen months after the new pediatric RRC guidelines became effective (February 1, 1997), pediatric residency program directors were queried regarding the implementation of these guidelines. The survey was sent to the 201 members of the Association of Pediatric Program Directors (APPD) in 2 mailings in August and September 1998. Twenty multiple-choice, open-ended questions were presented in a 6-page survey. Unless otherwise noted, each question was answered by >95% of respondents.^c Although surveys were coded for tracking purposes, the content of each individual survey has remained confidential. Survey results are, therefore, presented in aggregate form.

	RESULTS

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A final response rate of 70% was achieved. The representativeness of the survey sample was verified through demographic analyses of the respondents.^d The programs of both the respondents and nonrespondents were categorized first by program size to confirm the proportionate representation of all APPD member programs. Seventy-one percent of all programs with 25 or fewer residents returned a statistically valid survey, whereas 69% did so for programs with 26 to 45 residents, 82% for programs with 46 to 65 residents, and 76% for programs with 66 or more residents. The representativeness of the sample was also confirmed by calculating the response rate for programs in each US Census division: New England (91%), Middle Atlantic (73%), South Atlantic (74%), East North Central (76%), East South Central (90%), West North Central (60%), West South Central (63%), Mountain (86%), and Pacific (59%).

RRC Time Requirements for Training in Clinical Settings

With the exception of the intensive care experiences (neonatal intensive care unit and pediatric intensive care unit), >80% of the program directors reported little difficulty implementing the new RRC requirements. Those who reported difficulty with intensive care implementation cited insufficient financial resources, insufficient institutional support, and service demands for other aspects of the program as the primary barriers (Table 1).

Program directors were also asked to evaluate how well these time requirements prepare the pediatrician of the future to provide optimal care to children. An average of 96% believed that the time devoted to ambulatory setting, general inpatient pediatrics, and emergency and acute illness was adequate. However, 17% regarded preparation time as insufficient in neonatal intensive care unit (22%), intensive care (18%), behavioral/developmental pediatrics (16%), and adolescent medicine (13%).

In response to open-ended questions, program directors voiced their objections to the rigidity of the RRC guidelines. Many commented that greater flexibility is necessary, so that programs can prepare pediatricians to pursue diverse career paths in a variety of practice settings.

Acquisition of Other Competencies Mandated by the Pediatric RRC

A dozen new competencies were mandated by the Pediatric RRC (Fig 1). The new RRC guidelines, however, give only general indications regarding these 12 topics. The survey posed 2 questions to the program directors regarding these competencies. First, they were asked whether their residency program had defined the competencies by identifying the specific proficiencies and skills that residents should acquire as a result of their education in these competencies. As Fig 1 demonstrates, 50% or more of the program directors responded affirmatively for all of the competencies except for multicultural dimensions of health care (36%) and financing (41%).

View larger version (45K): [in this window] [in a new window]   Fig. 1.   A indicates multicultural dimensions of health care; B, community-based experience; C, medical ethics; D, professional behavior; E, health care organization; F, financing; G, practice management; H, quality assessment/improvement; I, risk management; J, cost-effectiveness; K, medical information sciences; L, child advocacy.

A second question asked whether a standardized curriculum for training in these 12 general competencies had been established in their residency program. Only 3 competencies garnered an affirmative response >50% (Fig 2). With the exception of community-based experience, medical ethics, and child advocacy, most programs had not established a standardized curriculum for training in these general competencies.

View larger version (47K): [in this window] [in a new window]   Fig. 2.   A indicates multicultural dimensions of health care; B, community-based experience; C, medical ethics; D, professional behavior; E, health care organization; F, financing; G, practice management; H, quality assessment/improvement; I, risk management; J, cost-effectiveness; K, medical information sciences; L, child advocacy.

A comparison of the responses to these 2 questions identified that only 3 of the 12 competencies (child advocacy, community-based experience, and medical ethics), for which >50% of the programs had identified proficiencies and skills, had also developed standardized curricula. On average, 35% of the programs had done both, ranging from a low of 15% for the multicultural dimensions of health care to a high of 65% for community-based experience. Conversely, approximately one third of programs have neither identified the proficiencies and skills nor developed curricula to teach them.

Survey respondents were asked to identify the methods by which their program currently teaches or plans to teach these competencies. Although lectures were the predominate method of instruction in all areas, interactive workshops, readings, and clinical settings were identified as additional methods of teaching the competencies. For all 12 of the competencies, at least 85% of respondents indicated that their respective programs provided some current training.

More than 50% of program directors believed that the quality of their program's training in the required competencies was excellent or satisfactory in all areas except medical ethics and professional behavior. This finding is particularly interesting, because many programs do not measure/evaluate the acquisition of competencies. Between 40% and 60% of the respondents stated that their program did not measure or evaluate multicultural dimensions of health care (47%), health care organization (60%), practice management (57%), quality assessment and improvement (51%), risk management (46%), cost-effectiveness (45%), and medical information sciences emphasizing skills for self-learning (41%). Programs cited observation of the resident, faculty comments, and resident comments as the most frequently used methods to evaluate resident competency. Other possible responses to the question were: completion of hours required by the program, written test, written evaluation of the resident, interview of the resident, patient/parent comments, and do not currently measure/evaluate.

Practice Settings

Respondents were asked to rate the overall quality of exposure provided to their program's residents in the 6 different practice settings: 1) private office-based practice for continuity clinic; 2) private office-based practice for outpatient rotation; 3) predominately managed care practice; 4) community clinics for continuity clinic; 5) community clinics for outpatient rotation; and 6) hospital-based practice for continuity clinic. Most program directors regarded the exposure provided in all settings to be excellent or satisfactory. However, 38% of program directors reported that their residents had no current exposure to private office-based practice for continuity clinic, whereas 33% indicated no current exposure to community clinics for continuity clinic.

Most program directors believed that the exposure to private office-based practice (64%) and community clinics (67%) was excellent or satisfactory. However, 19% reported no current exposure to private office-based practice, and 14% acknowledged no current exposure to community clinics for outpatient rotations. Predominately managed care practice was cited by nearly 18% of program directors as the setting for which quality of exposure was in greatest need of improvement. In a related response, most programs (67%) reported that they had no faculty development program for community-based pediatric generalist faculty.

In the inpatient setting, 87% reported adequate total numbers of patients seen, 88% reported adequate patients available per resident, and 92% reported adequate variety of patients. For outpatient settings 91%, 89%, and 95% reported adequate total number of patients, patient availability, and patient variety, respectively.

In response to an open-ended question, ~50% of the program directors provided insight as to how their program planned to improve exposure in 1 or more of these settings. Most underscored the need to develop more community sites and to expand the role or involvement of community and private office-based pediatricians in the training of pediatric residents. Program directors were also very satisfied with their residents' exposure to the number of patients seen, patients per resident, and the variety of cases.

Career Development

Overall, the majority of the program directors thought that the quality of their residency program's career development assistance was satisfactory or excellent.

Nearly all residency programs track board certification (99%) and participation of their residents in fellowship programs (94%). Almost one half of the respondents (48%) stated that their programs tracked subspecialty certification, whereas one third followed their graduates' participation in research. Publications (24%) and teaching careers of residents (30%) were not tracked as frequently.

Pediatricians in the 21st Century

A number of open-ended questions provided an opportunity for the program directors to comment on pediatric education in the 21st century. Respondents had been asked what changes they would recommend to convert the current minimal RRC requirements to optimal requirements for the education of pediatricians in the 21st century. In a related question, program directors identified possible methods for implementing these optimal requirements in the future. Respondents first advocated increasing the duration of rotations in developmental/behavioral pediatrics and in adolescent medicine. They then specified several requisite changes to achieve optimal standards: 1) more flexible rotations; 2) increased faculty, house staff, and physician extenders to meet service needs; 3) greater use of community resources and community-based sites and faculty; and 4) increased experience in ambulatory settings.

Program directors were queried as to what they believe will be the primary challenge for pediatricians in the 21st century. An overwhelming majority of the respondents who provided an answer to this question focused on concerns regarding the future role of pediatricians as the primary caregivers to children. Central to these concerns were the impact of managed care and allied health providers, such as pediatric nurse practitioners, physician assistants, and family practitioners, on health care delivery and workforce. Respondents communicated a shared conviction that pediatricians are and will continue to be the most competent and appropriate providers of care to children. Many program directors indicated, however, that pressures from managed care organizations and other sources to reduce the costs of health care have endangered the availability of such optimal care for the future. Excessive reliance on the services of allied health providers, respondents have asserted, will deny pediatricians the experience necessary to maintain their unique skills and to keep pace with developments in medicine and health care delivery.

Program directors were asked how pediatric residency programs could prepare pediatricians to meet future challenges. Although responses to this question varied, they communicated a common aim in preparing residents to be well-rounded providers of pediatric health care. The comments supplied involve improved preparation in 2 areas: clinical competency and administrative effectiveness. In the first area, it was affirmed that residents would need to receive more training in subspecialty areas to be able to treat chronically ill children. More exposure to different practice sites was also identified as a way of ensuring residents the breadth of experience they will need to provide optimal care to children. In the second area, program directors voiced the pressing need to improve resident education in the leadership aspects of health care delivery, such as practicing in a managed care environment, lobbying effectively, and engaging in child advocacy.

How then can residency education make pediatricians uniquely qualified to function as both members of a health care team and leaders in the organization and management of patient care in the 21st century? Most respondents to this question expressed the need for programs to produce residents who are trained as the optimal providers of health care to children, both in terms of clinical competency and management skills. Some respondents, however, admitted the need to perform outcome studies to determine an appropriate course for the future, whereas others did not know how this dual role could be achieved at all.

This prevailing view focused on educating well-rounded residents who can treat a variety of both generalist and subspecialty cases in diverse practice settings. Some respondents believed that it would be especially critical to emphasize the unique competencies of pediatricians that qualify them as the optimal providers of care to children. Many believe that only by demonstrating their broad base of knowledge and expertise will pediatricians avoid becoming triage practitioners who refer patients to allied health providers for general care. According to responses, ensuring the provision of optimal pediatric health care to infants, children, adolescents, and young adults remains and will continue to be entrusted to pediatricians both as individual providers and as leaders of health care teams.

	DISCUSSION

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This survey was fielded to solicit focused input on 4 topics: time requirements for training in clinical settings, acquisition of other competencies mandated by the pediatric RRC, practice settings, and career development. The first 2 topics were in response to specific changes in RRC requirements for residency training in pediatrics that became effective on February 1, 1997. The remaining topics addressed more general issues regarding the future of pediatric education.

RRC Time Requirements for Training in Clinical Rotations/Settings

The new requirements related to time spent in various training areas were easily implemented in most programs. As noted, the only exceptions were in intensive care areas where the service demands and the support for these service demands resulted in implementation problems. Although the majority of respondents regarded these requirements as very good or sufficient, a noteworthy percentage of program directors expressed concern over the preparation in behavioral/developmental pediatrics and in adolescent medicine.

Many program directors voiced their objections to the rigidity of the RRC guidelines and urged greater flexibility so that programs can prepare pediatricians to pursue diverse career paths in a variety of practice settings. Statistical data from other questions, however, suggest that their criticisms and concerns relate primarily to specific time restrictions for clinical rotations/settings and not the guidelines overall. This analysis is supported, moreover, by comments in which the respondents call for greater specificity and guidance relating to the implementation of the 12 competency areas listed in Fig 1.

Acquisition of Other Competencies Mandated by the Pediatric RRC

Most noteworthy among the comparative results are those pertaining to the multicultural dimensions of health care and financing. For both competencies, 51% of program directors responded no, thereby identifying that they had neither defined the skills and proficiencies that comprise them nor produced a curriculum for teaching these competencies. Respondents indicated that they had experienced greater success in the more established and commonly understood competencies, such as community-based experience and child advocacy.

The responses suggest that programs have been more successful in defining the new competencies than in developing curricula to teach them. Only in the areas of community-based experience, medical ethics, and child advocacy did more than one half of the respondents state that they had curricula. Although it may be argued that some of the remaining competencies are taught and can continue to be taught without formal curricula, this assertion does not satisfy the need to verify adherence to a common set of minimum standards for skills and proficiencies in these general competencies. If programs are to be held accountable for teaching and acquiring these competencies, then they must be provided with the means of demonstrating compliance with RRC guidelines. The limited number of curricula for teaching these competencies, which the survey has evidenced, verifies the need for more explicit definitions of these new competencies. Three of the competencies (health care organization, financing, and practice management), wherein a significant majority of the teaching is accomplished through lecture, are the same competencies that received the highest percentages of responses in the needs improvement category. Although this may indicate a need for other or more innovative teaching methods, it may also reflect the rapidly changing face of health care delivery. A pragmatic consequence of these changes is the difficulty program directors have had and will continue to have in identifying an adequate number of faculty who are both experienced and up-to-date on these topics.

The survey demonstrated that many program directors do not measure or evaluate competency acquisition. This is consistent with previously discussed findings that identified difficulties in defining competencies and/or developing curricula to teach them. The new RRC guidelines give only general indications regarding the proficiencies and skills that comprise these new competencies that programs must teach. This ambiguity makes it difficult for program directors and the RRC to determine whether programs are in compliance with these guidelines. Such a difficulty might be addressed by the development of a set of measurable and qualitative standards for teaching these competencies in all programs.

Practice Settings

The majority of respondents indicated that their residents' exposure to the 6 practice settings was excellent or satisfactory. It was not possible in this survey, however, to determine the number of residents per program that received exposure in these settings, or whether these experiences were required or elective.

In contrast, approximately one third of the respondents identified 1 or more setting(s) in which their programs had no current exposure. To understand this lack of exposure, it may be necessary to determine on a program-by-program basis whether it is attributable to a lack of access to such sites, as in rural and underserved areas, or whether it is attributable to organizational, financing, or other issues.

A significant percentage of respondents (67%) indicated that they do not have a faculty development program for community-based pediatric generalist faculty. This raises a serious concern for the future of medical student and resident education. This issue was previously illustrated by the lack of resident exposure to private office-based and community-based practices for continuity clinic and the identified need to offer greater exposure in these settings. Thus, the expanding need for community-based generalist faculty in medical student and resident education will require more faculty development programs to recruit an adequate number of community-based faculty for this role.

Career Development

Based on the responses to questions about the types of career development assistance offered to residents and the types of follow-up tracking of residents, program directors have communicated no serious concerns in either area. Most program directors identified the American Board of Pediatrics as the primary source of their follow-up information on board certification and participation of their former residents in fellowship training programs. Questionnaires and continued contact with graduates were cited as other sources of information. The publications and teaching careers of residents were not tracked as frequently. Program directors revealed that much of their knowledge about the career development of their graduates is obtained through informal means, such as reading publications, contacting individual residents, and attending conferences.

Pediatricians in the 21st Century

Many program directors believe that RRC guidelines leave little latitude for a program to shape residency education to meet the needs or goals of an individual resident or program in terms of regional, workforce or financial concerns, or changes in health care delivery. RRC guidelines, however, currently represent a minimum standard of requirements, which, as discussed above, comprise the only uniform measure of quality for pediatric residency education. In recent years, it has been suggested within the pediatric community that fulfillment of time requirements alone does not accurately measure resident competency. They have, therefore, argued for the development of alternate outcomes measures.

In addition, the general pattern of response indicates the need to conduct outcomes studies to determine appropriate roles for pediatricians, both general and subspecialist, and for other providers of care to children. Such studies are essential in managing pediatric health care in the 21st century in terms of cost, quality of outcomes, and workforce. Furthermore, the diverse recommendations for the preparation of residents display the overwhelming priority according to program directors to secure and underscore the unique role and skills of the pediatrician in the health care system. In general, respondents believed that the combination of clinical expertise and administrative skill would allow pediatricians to assume a leadership position, while functioning as part of a health care team.

	CONCLUSION

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We recognize the limitations to this survey; the findings are drawn exclusively from the subjective expertise, experience, and perspectives of pediatric residency program directors. Input from other participants in the educational process, such as residents and faculty, was not solicited. Despite the overall candor of responses and comments, we acknowledge that individual respondents may have chosen to emphasize the strengths, rather than the weaknesses, of their respective programs.

The extent and quality of the responses to the survey suggest that the questions presented accurately reflected concerns in the pediatric community regarding the future of pediatric residency programs. These concerns, coupled with the high response rate to this survey and the individual questions, point to the need for conducting similar surveys on a regular and ongoing basis by an independent entity or organization. The data and individual responses have also demonstrated the need for outcome studies on a variety of topics to inform the development of pediatric residency education. Outcomes studies should investigate issues and concerns including, but not limited to, the use of community-based sites and faculty, the relative efficacy of specific training modalities and sites, and the appropriate roles in health care delivery for pediatricians and nonpediatrician providers of health care to infants, children, adolescents, and young adults.

Program directors seek more specific information and consultative guidance, on a continuing basis, to ensure their optimal compliance with RRC requirements. They repeatedly identified the need for more detailed and comprehensive definitions of the competencies to be acquired by residents. There is a need to respond to the request for greater flexibility in the duration of rotations and the number and types of electives. It must be determined, moreover, whether such flexibility would facilitate the preparation of pediatricians who will be able to deliver optimal health care to children in a variety of settings. A permanent mechanism to provide ongoing guidance must be developed. This mechanism would also aid residency programs in developing and implementing curricula to teach the mandated competencies. It may not be within the purview of the pediatric RRC or its parent body, the ACGME, to provide such services. Therefore, it would be appropriate for groups and organizations within the pediatric community to take the lead in developing such a mechanism. The findings from this survey 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.

	ACKNOWLEDGMENTS

This work was supported in part by funding/grants from the American Academy of Pediatrics, American Board of Pediatrics Foundation, Association of Medical School Pediatric Department Chairmen, Center for the Future of Children of the David and Lucile Packard Foundation, and Project MCJ-379381 from the Maternal and Child Health Bureau.

We gratefully acknowledge the advice and insights provided by the following individuals who reviewed the survey instrument and/or this article: Carol D. Berkowitz, MD, FAAP, Past President, APPD; Marvin Dunn, MD, Past Secretary, American Medical Association Council on Medical Education; the members of the Future of Pediatric Education II Project's Education of the Pediatrician Workgroup, including Evan Charney, MD, FAAP, Chairperson; Diane Kittredge, MD, FAAP; and Lawrence F. Nazarian, MD, FAAP; and Sarah E. Brotherton, PhD, and Karen G. O'Connor from the American Academy of Pediatrics, Division of Health Policy Research.

The survey of APPD members and this article would not have been possible without the encouragement and assistance of Errol R. Alden, MD, FAAP, Principal Investigator, Future of Pediatric Education II Project.

We also acknowledge the support of Robert Nolan, MD, FAAP, President, APPD, for encouraging participation in the survey.

Finally, we thank those pediatric residency program directors who generously contributed their professional expertise and time to the survey.

	FOOTNOTES

Ms Mulvey and Mr Ogle-Jewett are currently in the Division of Graduate Medical Education and Pediatric Workforce, American Academy of Pediatrics, Elk Grove Village, Illinois.

^a Because the pediatric community has not achieved consensus on the usage of the terms training and education, these are used synonymously in this article, according to the accepted usage of the organizations and individuals concerned.

^b Per the 1998-1999 Graduate Medical Education Directory, there is a an RRC for each of the specialties in which certification is offered by a specialty board that is a member of the American Board of Medical Specialties. The members of the pediatric RRC are appointed by each of the following sponsoring organizations: American Board of Pediatrics, the American Academy of Pediatrics, and the American Medical Association, Council on Medical Education. The Program Requirements for pediatrics are developed by the pediatric RRC. All RRCs operate under the auspices of the Accreditation Council for Graduate Medical Education (ACGME). The RRC then decides on the final proposal to be submitted to the ACGME. The ACGME has final authority for approving all program requirements. In developing and updating the program requirements, the RRC obtains comments on the proposed documents from interested parties and agencies. The program requirements specify essential educational content, instructional activities, responsibilities for patient care and supervision, and the necessary facilities of accredited programs in pediatrics. The program must demonstrate to the pediatric RRC that it is in substantial compliance with the program requirements for pediatrics, and that it is sponsored by an institution in substantial compliance with the institutional requirements. Accreditation actions taken by the review committee are based on information submitted by program directors and on the reports of site visitors.

^c Responses that provided contradictory or other unusable information were coded as invalid but did not affect the general trends demonstrated by the data. These invalid responses comprised a negligible percentage of the total.

^d Only 191 of the queried 201 members of the APPD were used for demographic analysis, because some nonrespondents could not be identified with an ACGME-accredited program, or represented a program for which a survey had already been returned by another member. Demographic information from 1 member of the APPD was also excluded from the analysis because she/he represented a Canadian program.

Received for publication Apr 6, 1999; accepted Oct 8, 1999.

Reprint requests to (H.J.M.) Division of Graduate Medical Education and Pediatric Workforce, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007-1098

	ABBREVIATIONS

RRC, Residency Review Committee; APPD, Association of Pediatric Program Directors; ACGME, Accreditation Council for Graduate Medical Education.

	REFERENCE

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1. American Medical Association. Graduate Medical Education Directory: 1998-1999. Chicago, IL: American Medical Association; 1998