Published online December 16, 2008
PEDIATRICS Vol. 123 Supplement January 2009, pp. S59-S60 (doi:10.1542/peds.2008-1578N)

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SUPPLEMENT ARTICLE

Looking to the Future

Gail A. McGuinness, MD^a and M. Douglas Jones, Jr, MD^b

^a Executive Vice-President, American Board of Pediatrics, Chapel Hill, North Carolina
^b Department of Pediatrics, University of Colorado Denver, School of Medicine, Aurora, Colorado

	ABSTRACT

TOP ABSTRACT ACCOMPLISHMENTS TO DATE REMAINING CHALLENGES PRACTICAL CONSIDERATIONS VISION FOR THE FUTURE:... REFERENCES

 
Participants of the Residency Review and Redesign (R³P) Project have created a challenging strategic plan for pediatric residency education. In place of a list of prescriptions for immediate change, the R³P Committee recommends an ongoing project of goal-directed change, a quality improvement approach to resident education. It argues for changes based on evidence of important education outcomes that improve the health of children, adolescents, and young adults. Creation and maintenance of a process of ongoing, adaptive change will depend on the combined efforts of the Association of Pediatric Program Directors, the Association of Medical School Department Chairs, the American Board of Pediatrics, the Resident Section of the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education Review Committee for Pediatrics.

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Key Words: education • medical • graduate • decision-making • organizational • organizational innovation • program development • certification • accreditation

Abbreviations: R³P—Residency Review and Redesign in Pediatrics • ACGME—Accreditation Council for Graduate Medical Education

As the Residency Review and Redesign in Pediatrics (R³P) Project comes to its conclusion in 2009, it is imperative to be specific and clear about the expectations for the future. As described in this supplement to Pediatrics, the project began as an initiative to assess the duration and content of general pediatrics residency training and make specific recommendations for the future, but it has since evolved into an ongoing process of innovation. Thus, we must begin to think about residency training in a different way and recognize that conducting the business of graduate medical education is a project that is never complete and requires acknowledgment of a certain degree of ambiguity and uncertainty. Just as societal mandates for quality, accountability, and evidence-based assessment of clinical outcomes are transforming pediatric health care, a similar transformative process is occurring in graduate medical education.

	ACCOMPLISHMENTS TO DATE

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Over the past 3 years, the R³P Project sponsored 3 colloquia (documented in detail at www.abp.org and elsewhere in this supplement) and held numerous meetings with stakeholders in pediatrics graduate medical education. The shared dialogue, experiences, and perspectives of these groups led to consensus in the development of 2 documents that will serve as the underpinning for innovative change in pediatrics graduate medical education going forward. The first of these documents describes a number of themes that must be considered in designing future pediatrics residency education over the next 15 to 20 years and, in acknowledging many uncertainties, argues for models of pediatrics education that are flexible enough to provide for a variety of professional futures.¹ In the second document, the R³P Project identified clearly defined goals for innovation that are most likely to result in transformative change.² The goals are deliberately few in number to provide focus and clarity and to serve as a road map for the future.

Finally, as articulated in this supplement, the R³P Project and R³P Committee endorsed a model in which responsibility for education innovations would reside primarily at the training-program level, ideally with collaborative groups of programs. This decentralized process will allow full use of the knowledge, problem-solving ability, and strength of individual programs and institutions.

The R³P Project has begun collaboration with the Review Committee for Pediatrics of the Accreditation Council for Graduate Medical Education (ACGME), a partnership vital for ultimate success, to develop methods by which training might be modified to meet these specific goals and to facilitate the evaluation of requests for waivers of current training requirements if needed. The R³P Project has been successful in bringing together partners that are crucial to moving forward in addressing the goals for innovation. In addition to the ACGME and the American Board of Pediatrics, the interests of the Association of Pediatric Program Directors, the Resident Section of the American Academy of Pediatrics, and the Association of Medical School Pediatric Department Chairs are paramount.

	REMAINING CHALLENGES

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Significant challenges remain. Innovation must take place within the context of oversight and regulation. External oversight and peer review of training programs by the ACGME and the establishment of national performance standards by the American Board of Pediatrics will be necessary despite the emphasis on a decentralized means of testing innovative solutions to important problems. The challenges associated with promoting innovation are formidable: how to initiate, facilitate, and sustain it; how to oversee it; and how to identify and disseminate effective innovations. Volunteerism and goodwill in and of themselves will not sustain innovation. There is a general consensus that a specific entity will be required to assume responsibility for implementing the goals of the R³P Project and to provide an infrastructure to support the process, serve as a central data repository, provide consultation to programs, facilitate innovation, and assist with the dissemination of results. No one organization can be the sole "home" for such an entity; it will require the commitment and partnership of multiple stakeholder organizations and represent their perspectives.

	PRACTICAL CONSIDERATIONS

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Members of a subcommittee that consists of representatives from the R³P Committee and the Review Committee for Pediatrics have begun drafting a document to solicit proposals. The approach relies on experience gained with the Educational Innovation Project in internal medicine³ and the Preparing the Personal Physician for Practice (P⁴) initiative in family medicine.⁴ It will invite proposals from programs, preferably consortia of programs, that offer innovative solutions to the list of challenges in residency education.² Foremost will be the 3 major goals identified as those most likely to result in transformative change in residency education. Responses might include requests for waivers of ACGME program requirements. The Review Committee for Pediatrics is currently discussing procedures by which waiver requests would be handled, along with ways that such programs would be monitored. All programs would need to have a plan for measuring outcomes; proposals for more dramatic change would be expected to have a correspondingly sophisticated plan for measuring and analyzing consequences. The likely complexity of proposals, and the external and internal monitoring that will be required, means that only a limited number can be approved. Therefore, the committee is committed to exploring with the Association of Pediatric Program Directors and others the possibility of parallel creation of 1 or more resident education "learning networks." These would be intended to facilitate collaboration among multiple programs to address specific goals according to the interest and capability of individual participants. The objective would be to accelerate the transformation of residency education by measuring and sharing outcomes. Over time, participants would learn from one another and, ultimately, teach us all.

	VISION FOR THE FUTURE: OUTCOMES IN 5 TO 10 YEARS

TOP ABSTRACT ACCOMPLISHMENTS TO DATE REMAINING CHALLENGES PRACTICAL CONSIDERATIONS VISION FOR THE FUTURE:... REFERENCES

 
The desired outcomes in 5 to 10 years are summarized here on behalf of the R³P Project and R³P Committee:

1. Transformation of residency to match the transformation of pediatrics by using a sustainable process to respond to changing health care needs, variations in health care delivery systems, and new methods of assessment of clinical competence.
   
2. Evidence-based education using a flexible system to continuously seek evidence-based improvements in what and how pediatricians are taught.⁵
   
3. Better preparation for a career, with residency training tailored to meet the diverse career needs of individuals choosing to care for patients with a variety of health-related needs in different settings.
   
4. Better-integrated and continuous learning, with a seamless transition from medical school and residency education in a competency-based system to a competency-based certification process using similar measurement tools.⁶
   
5. Sustained innovation with a centralized entity to support and facilitate innovation and assist with the dissemination of results.
   
6. A new model for accreditation using results of innovative projects that will inform future iterations of ACGME program requirements with an evolution of training program structure and content that is evidence based with the potential to be time variable.^5,7
   
7. Better health care and health for children, adolescents, and young adults.
   

These goals are ambitious. With sufficient time, focus, and patience, they are eminently achievable. Nonetheless, to quote Dr Larry Green, a leader of the Preparing the Personal Physician for Practice initiative in family medicine and a member of the R³P Project Group, "It will not be a project for the fainthearted."

	FOOTNOTES

 
Accepted Sep 22, 2008.

Address correspondence to Gail A. McGuinness, MD, American Board of Pediatrics, 111 Silver Cedar Ct, Chapel Hill, NC 27514. E-mail: gam{at}abpeds.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP ABSTRACT ACCOMPLISHMENTS TO DATE REMAINING CHALLENGES PRACTICAL CONSIDERATIONS VISION FOR THE FUTURE:... REFERENCES

 

1. Lister G, Murdock-Vlautin TC, Friedman AL. Report of colloquium I: the future of pediatric health care delivery and education—pondering imponderables to create an ideal residency in a world of critical uncertainties. Pediatrics. 2009;123 (1 suppl):S12 –S16[Abstract/Free Full Text]
2. Abbott MB, First LR. Report of colloquium III: challenges for pediatric graduate medical education and how to meet them—a quality improvement approach to innovation in pediatric graduate medical education. Pediatrics. 2009;123 (1 suppl):S22 –S25[Abstract/Free Full Text]
3. Accreditation Council for Graduate Medical Education. Educational Innovation Project. Available at: www.acgme.org/acWebsite/RRC_140/140_EIPindex.asp. Accessed March 31, 2008
4. Green LA, Pugno P, Fetter G Jr, Jones SM. Preparing the Personal Physician for Practice (P⁴): a national program testing innovations in family medicine residencies. J Am Board Fam Med. 2007;20 (4):329 –331[Free Full Text]
5. Leach DC. Building and assessing competence: the potential for evidence-based graduate medical education. Qual Manag Health Care. 2002;11 (1):39 –44[Medline]
6. Brown HJ, Miles PV, Perelman RH, Stockman JA III. A continuum of competency assessment: the potential for reciprocal use of the Accreditation Council for Graduate Medical Education toolbox and the components of the American Board of Pediatrics maintenance-of-certification program. Pediatrics. 2009;123 (1 suppl):S56 –S58[Abstract/Free Full Text]
7. Goroll AH, Sirio C, Duffy FD, et al. A new model for accreditation of residency programs in internal medicine. Ann Intern Med. 2004;140 (11):902 –909[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics

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