PEDIATRICS (doi:10.1542/peds.2008-0719)
SPECIAL ARTICLE |
Part-Time Training in Pediatric Residency Programs: Principles and Practices
a Boston Combined Residency Program in Pediatrics (Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, and Department of Medicine, Harvard Medical School and Children's Hospital Boston), Boston, Massachusetts
b Federation of Pediatric Organizations Task Force on Women in Pediatrics, Chapel Hill, North Carolina
c American Board of Pediatrics, Chapel Hill, North Carolina
d Department of Pediatrics, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Despite growing interest in part-time work, few pediatricians are pursuing part-time residency training. There is currently little guidance for programs or residents who wish to design an alternative path through residency. In this article we review the need for part-time residencies and address obstacles to be overcome in their initiation. Strategies are offered for residents and program directors planning part-time training pathways, with recommendations for implementation amid a changing environment for graduate medical education. The needs of trainees, residency programs, hospitals, and credentialing organizations are considered.
Key Words: part-time • medical residency • graduate medical education • pediatric workforce
Abbreviations: UCSF—University of California, San Francisco • Match—National Resident Matching Program • ABP—American Board of Pediatrics • ACGME—Accreditation Council for Graduate Medical Education • RRC—Residency Review Committee • FTE—full-time equivalent • GME—Graduate Medical Education
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Part-time residencies have been implemented in a variety of specialties since the 1970s. Changing demographics, including more women in medicine and new generations concerned with lifestyle management, suggest that interest in this training option will grow.1 With its high percentage of women physicians and professional focus on family health, pediatrics is likely to be at the leading edge of any movement to part-time training.2 Nevertheless, at present few pediatric programs and even fewer residents are publicly using reduced-hours schedules, and there is little guidance for how to do so effectively.3,4
It is our goal to review the growing need for part-time solutions and to address the potential pitfalls. Because each program is structured differently, individual programs will need to create solutions that work in their own environment. We hope to encourage this practice by sharing examples of successful models of part-time training, including reduced-hours, shared positions, and prolonged or variable periods of absence.
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WHAT IS THE DEMAND FOR PART-TIME TRAINING? |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Evidence suggests that there is unmet demand for part-time work during residency. Medical students report strong interest in part-time training and are increasingly choosing specialties with controllable lifestyle.5,6 Beyond residency, 23% of board-certified pediatricians are working part-time (up from 11% in 1993).7–9 Nevertheless, currently only 12% of pediatric programs report offering part-time schedules, and fewer than 1% of pediatric residents report working part-time.3,4 Fig 1 summarizes these data.
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Demographic and cultural trends indicate that this demand may increase. Female gender is a strong predictor of seeking part-time employment, and in the last 15 years the proportion of female pediatrics residents has grown from 58% to 72%.9,10Although to a lesser extent than women, young male physicians also increasingly seek part-time work, possibly reflecting changing cultural norms in the era of the dual-career family.5,9,11
In 2 large pediatric programs (our own Boston Combined Residency Program and the University of California San Francisco [UCSF]) that have offered a "blocks on/blocks off" training schedule after internship, 8% to 9% of residents elected this option. In the UCSF report of their 10-year experience, an additional 7.4% of residents using the regular schedule regretted not taking advantage of the option.12
Looking to other fields, it is interesting to examine general surgery. The implementation of the 80-hour workweek in 2003 represented a 20% decrease in general surgery residents' hours, but applications to general surgery residencies have remained stable.13,14 Whether additional lifestyle enhancements during training would affect applications to this or any specialty is unclear. Still, in a national survey of surgical trainees conducted after 2003, 25% of female and 13% of male residents expressed interest in a part-time option (40–80 hours weekly, with a proportionate increase in length of residency).5 The same authors found that 24% to 36% of medical students (male and female, respectively) agreed to increased interest in surgical careers if part-time training 40 to 80 hours per week were an option.5 Smaller studies corroborate that students believe work-hour limitations enhance the lifestyle of surgeons and make the field more attractive.15,16
On the basis of these data, we estimate that expanding and publicly offering part-time options may yield 
10% to 15% of residents arranging part-time training.
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WHY PART-TIME TRAINING? |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Taking a "big picture" view, one could argue that by incorporating part-time training pathways pediatrics as a field will attract and retain the best talent. For individual institutions, the sense of loyalty created by investment in balanced lifestyles during the period of training may create a long-term mutually beneficial and productive relationship.17 This may be particularly important for encouraging women to pursue academic careers.
As pediatricians we are also committed to the development of healthy families. We would be better able to role-model healthy family behaviors for our patients if we could provide employment structures for all of our physicians, including trainees, to satisfactorily attend to their home life. Indeed, the primary reason pediatricians seek part-time employment both during training and postresidency is to balance work and family responsibilities.3,7,9
Biologically this issue is most acute for women. Prolonged absences from home and odd hours during training necessitate special arrangements for child care and lactation. Classic reports raise concerns about the effect of prolonged work hours on the health of a pregnancy.18,19 Similarly provocative work shows negative effects of prolonged periods of nonmaternal care on some aspects of infant social development.20–22
For all of these reasons the Federation of Pediatric Organizations Task Force on Women in Pediatrics and the Women Chairs Group of Association of Medical School Pediatric Department Chairs have both recently published consensus opinions endorsing the need to create part-time work options for pediatricians in training and beyond.17,23
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OBSTACLES TO CREATING PART-TIME RESIDENCIES |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Despite the apparent need, creating part-time solutions poses many challenges. Real and perceived obstacles likely contribute to current low utilization rates.
Knowledge and Access
From the perspective of residents, the first obstacle is awareness that a part-time option may exist. Although a program may formally report a part-time option, the failure to advertise it actively and/or the lack of participating residents may create the impression that part-time employment is impossible. Medical student applicants may be educated about the availability of part-time options through the Fellowship and Residency Electronic Information Database, via a program Web site, or via advisors at their school. It is therefore important for program directors to ensure that these information sources are updated.
Access to part-time internships or shared residencies is particularly problematic. Residency positions are acquired through a national matching system (National Resident Matching Program, "the Match"), which connects graduating medical students with residency programs. Although there is a formal process for entering the Match as a pair applying to 1 full-time slot in a participating program, very few residency programs participate. There is also no national coordination effort to aid applicants in finding an appropriate counterpart. The partnering is critical because the overall potential for the dyad to match is generally based on the weaker applicant, and if the pair is matched to a full-time position, both individuals are bound by the terms of the Match to accept it.24,25 If offering shared internships through the Match, program directors must carefully evaluate each member of the dyad on individual merits. For this practice to be disseminated, it will require additional education of program directors, such as occurs through efforts of the Association of Pediatric Program Directors.
Impact on the Resident
Even when in possession of the necessary knowledge and access to pursue part-time work, residents must consider practicalities. Financially, residents may not be able to afford to work part-time, particularly if benefits are tied to a full salary.7 The affordability of the part-time option is a real problem to incoming residents, 85% of whom carry medical school debt, with a median of $140000.26 This problem is compounded by rising interest rates and the elimination of deferment programs. Although some salary deficits can be bridged through moonlighting opportunities, this is not generally true for fringe benefits. The need for benefits to accompany salary is especially important for health care coverage if the request for part-time work is related to the care of young children, who require significant routine health care. As a corollary, some may not wish to extend the period of training, either because of salary needs or future plans.5 Similarly, for residents studying in the United States from other countries, there are significant visa implications for part-time pathways both as a function of exceeding the duration of the visa and mandates for full-time employment. This is especially true for those with J1 visas, which do not allow part-time training.
Other concerns include completing residency "off-cycle," which may affect fellowship applications or social relationships between residents. Residents may also fear that they would be perceived as overburdening full-time resident colleagues. In addition, physicians wishing to pursue research careers may believe that choosing or even investigating a part-time pathway may negatively impact their advancement.27–30
It should be noted that the presence of a part-time option, although engendering some feelings of resentment among colleagues, overall has been supported by full-time residents within the same program, who found the presence of the part-time option provided a sense of support that enabled them to cope with the stresses of residency.12
Program Considerations
Program directors, who need to balance training requirements with hospital service needs, may not fully embrace part-time training because of the complex administrative challenges that customization imposes. These challenges encompass planning, scheduling, documentation, and expense. When an individual resident requests a modified work schedule, the impact on day and night staffing, documentation of competency, and finances of paying the resident and any necessary replacement all must be considered. The customization process must be planned far enough in advance to consider workforce needs and allow for midtraining hires, increasing match numbers, advertising shared positions, or finding alternatives to house officers (eg, "physician extenders"). Ideally, a program could hire enough residents in advance to account for potential fluctuations in workforce, eg, because of parental leaves or midyear schedule reductions. This "buffer" may not be financially feasible for all programs.
Once a mutually satisfactory reduction in hours has been agreed on, an accommodating schedule and salary structure must be designed. The increased scheduling complexity on both a long-term planning and a daily basis requires active management by appropriately trained staff. This is especially true if the part-time status varies over time for a single resident or if more than 1 resident is part-time and the same schedule is not used. During the implementation phase, monitoring progress toward the goals of physician competency must continue. The growing availability of computerized scheduling tools and competency-based assessments should ultimately aid in these at times cumbersome tasks. Finally, maintaining strong communication about day-to-day residency issues and long-term planning issues is critical. Fortunately, the ubiquity of e-mail can facilitate such interactions when a part-time resident is off-campus for a prolonged period: either direct explanations, invitations to "town meetings," or minutes of meetings can keep everyone current.
Certification Considerations
The American Board of Pediatrics (ABP) is responsible for the certification of individuals and the assurance to the public and the profession that individuals have successfully completed an accredited educational program and have the knowledge, skills, attitudes, and behaviors to provide high-quality care. In 1992, the ABP began a robust tracking and evaluation program that requires program directors to provide yearly evaluations of the clinical competence and professional behavior of all residents and to indicate the number of months of training credit to be applied to the requirements for certification (33 months, with possible 2 months waived for family leave). The tracking program assures the appropriate monitoring is in place to permit deviations from the usual training pathways, such as part-time training. This system has enabled flexibility without compromising educational quality. Options currently include transferring from one program to another, taking a leave of absence, and engaging in part-time or shared training.
The Credentials Committee of the ABP will review plans for part-time or shared training opportunities on request. Although preapproval is not required, the ABP will advise on whether the proposed program adequately meets the goals of training. Program directors tend to contact the ABP when they are devising an unusual or complicated training structure (eg, night-call only without daytime responsibilities, or prolonged absences). The program director should articulate a clear rationale for the training plan, address any potential concerns regarding diluted training or lack of immersion in the discipline, and must assure the ABP that the schedule will provide a full training experience, albeit on an extended time table. The program director must document annual progress reports and at the completion of training verify that the resident is competent to enter practice without direct supervision.
Ultimately, for the ABP to certify an individual it is imperative that the core training requirements established by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Pediatrics are met. For example, those individuals who are training on a part-time basis should have the same degree of responsibility for patient care as the traditional resident and engage in the same supervisory experiences and in a continuity clinic that is longitudinal in nature.
The ACGME has defined 6 competencies that must be achieved by the end of residency training: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The ABP and RRC further delineate specific pediatric training goals for each competency. A program must specifically document progress toward these goals. For each competency, there are several principles underlying the RRC pediatric program requirements that must be carefully considered when customizing a part-time schedule. Meeting the competencies with a part-time schedule is potentially complex. Illustrative challenges posed by part-time training and examples of possible solutions are provided for each competency in Table 1.
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It should be noted that part-time residents might best meet some competencies. Indeed, in a study of internal medicine residents, part-time trainees were rated higher than their counterparts in interpersonal skills and humanism.31 This may represent a self-selection bias, closer relationships with the advisors performing the evaluations, or perhaps decreased burnout among residents working part-time.
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PART-TIME TRAINING IN PRACTICE |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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Although experience with part-time residencies is not broad, there are multiple existing models. We will discuss here the job sharing model and its variations, as well as the impact of each model on the resident and program.
The job-sharing option may be conceived "in series" or "in parallel." An "in series" model involves mixing blocks of time of full-time training with blocks of time off, in the model of "1-month on, 1-month off" or larger groups of blocks on and off. That is, for each month-long rotation, either 1 resident or the other is on duty. In a smaller program, this model may necessitate specific pairing of 2 part-time residents so that rotation schedules remain intact. In 1 small program, a husband-wife team recently job-shared in this fashion so that 1 would always be home with their infant. In larger programs there may be sufficient interest in fractional positions that several residents can combine to create the appropriate workforce. For example, 5 residents each working 0.8 full-time equivalents (FTEs) combine to work as 4 resident FTEs. This model preserves continuity within each rotation; however, it requires attention to maintaining a presence in longitudinal clinics during "off" months. With more residents to fill a stable number of full-time equivalents, a program may benefit from increased staffing flexibility. Some additional effort may be required to keep the residents connected to the program educationally and socially during the off months. This was the model chosen by UCSF, and of note, their board passage rates between "flexible option" and "regular schedule" residents did not differ significantly.12
The "in parallel" model has each resident sharing a role within a rotation schedule. In our program, we use this model to accommodate rotating family practice residents on our wards because this group must participate in more outpatient clinics during the week. In this arrangement, 2 residents are assigned the same schedule, and they work together to cover the same patient load. The night call is alternated between the 2, so that on an every fourth night rotation each individual takes call every eighth night. The daytime responsibilities are either shared during the day, or covered by 1 resident when the other must be off the ward. For pediatrics residents seeking more flexible time to attend to outside responsibilities or interests, this model reduces the frequency of evening call and provides more flexible time during the day (eg, if 1 resident needs to be home 1 afternoon, the other is available to cover patients). This system may also forge a bond between the sharing residents that may satisfactorily replace any loss of connectedness to a class. This model works well for preserving continuity clinics, but requires more inpatient handoffs that could potentially disrupt continuity of care to the detriment of the patient and/or to the resident's education. It also may be more difficult for faculty to evaluate individuals with such an enmeshed patient load and with reduced overall contact.
Some programs have divorced day and night coverage, allowing for an easier "shift work" approach to scheduling a part-time option. For example, on a subspecialty rotation that has night and weekend call on the wards on an every fourth night basis, roughly one half of the time is spent on the daytime weekday rotation and the other half is spent on night and weekend call coverage. Therefore, splitting weekday daytime responsibilities on the subspecialty rotation from the night and weekend call can create 2 part-time positions each at 0.5 FTEs. Program directors must decide which rotations are amenable to such a split: some would argue that inpatient ward rotations are not amenable to a split because of the impact on continuity of care. Similar approaches to splitting full-time rotations into part-time rotations can be done on a rotation-by-rotation basis and the pro rata share apportioned to the split roles. The "split roles" model allows for a good degree of predictability in the schedule and minimal extended shifts, especially beneficial for those with child care responsibilities.
Pediatricians or physician extenders could be hired to supplement some or all of the uncovered service requirements of part-time residents. This approach was commonly employed in response to New York State work-hours restrictions initiated in 1989 (the "Libby Zion" law) and in response to the ACGME duty-hours restrictions in 2003, with approximately one third of pediatrics residency programs using this option32–34 Follow-up studies of residents and program directors in pediatrics and other fields employing nonphysicians indicate positive impact on resident education, quality of life, and career preparation.32,35 To date, this option has not been widely used specifically to allow for part-time training. This may be because of the relative infrequency of part-time residencies or to expense.
All of these options allow for varying the percentage of FTEs for an individual during part or all of residency. In aggregate, these options have delayed graduation by an average of 15 months.3
At the departmental level, these scheduling efforts need to be supported by appropriate assignment of benefits to make the option financially feasible both for the department and for the resident. Of note, the use of part-time pediatric residents should not impact a hospital's Graduate Medical Education (GME) funding, whether a stand-alone children's hospital or a department within a general hospital. The funding is based on total full-time equivalents and is not specifically attached to individuals.
Establishing a time line within a department is critical for managing the complex logistics and smooth implementation of part-time residencies. A program should plan to know as much as possible their staffing expectations 9 months in advance of the upcoming academic year. This allows time for adjustment of numbers to match into an intern class, to recruit into an upper level class, and/or to arrange job-share opportunities. The particulars of the part-time schedule should be sketched out at this time, including percentage of full-time and concomitant salary benefits, as well as the basic structure, with actual day-to-day responsibilities filled in as the academic year approaches.
Although perfect knowledge 9 months in advance is impossible, our program uses some effective strategies that enhance our ability to anticipate future absence. These include a formal letter from the program directors sent in October requesting a commitment for the following academic year and a consideration of the likely number of pregnancies. The "likely pregnancies" is a relatively stable number in our program year-to-year, representing 10% to 15% of female senior residents and 5% of female junior residents; annual estimates are bolstered by a culture of confidence in our residency coordinator, who is often informed of an intention to become pregnant so that this information may be considered confidentially when arranging scheduling.
In current practice, the majority of part-time work is established after the intern year. This practice may exist because of lack of infrastructure for hiring part-time interns through the Match, or because the need for a part-time option does not become apparent and workable until after one has already lived residency. In our experience, flexible schedules often arise as crisis interventions. That is, a discussion about reduced workload too often occurs after a resident struggles with the standard schedule. When proactive discussions of training trajectory are initiated, as part of a regular review, "part-time" is dissociated from failure, and becomes a positive intervention. Such proactive discussion may thus prevent considerable stress and frank morbidity among residents who desire increased flexibility, whereas at the same time allowing the program to better predict staffing needs and avoid overwhelming other residents who would otherwise need to cover in a pinch.
In addition to schedule planning, educational planning is also critical. Changes in how we deliver education and monitor progress will contribute to improved feasibility of part-time residencies. Acquisition of factual medical knowledge during a nontraditional schedule may occur through a variety of offsite modalities both interactive (video-conferencing, video calls) and noninteractive (reading assignments, Web-casting lectures). Simulated training experiences (eg, with electronic patients) are in increasing use to supplement training. This modality is useful for improving instruction and assessment in all of the competencies, and can be scheduled flexibly.36 As we move to competency-based assessment, reliance on time-in-training to determine board eligibility may decline, thereby enhancing the feasibility of reduced-hours schedules for some residents. Competency-based assessment may even allow for academic credit for parental leave, during which many basic pediatric lessons are absorbed.23 The trend toward creation of written curricula, case-logs, and individualized multi-source feedback instruments will improve the ability to monitor satisfaction and productivity in both traditional and alternative schedules. Such monitoring, at both the local and national levels, will be critical for the success of part-time programs.
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SUMMARY AND RECOMMENDATIONS |
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TOPABSTRACTINTRODUCTIONWHAT IS THE DEMAND...WHY PART-TIME TRAINING?OBSTACLES TO CREATING PART-TIME...PART-TIME TRAINING IN PRACTICESUMMARY AND RECOMMENDATIONSREFERENCES |
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There is a growing need for part-time training solutions in pediatrics. Although the current experience is limited, it provides some guidance with respect to successful implementation and potential pitfalls. Changes in the way education is delivered and assessed may enhance our ability to provide part-time training. We suggest the following for training programs:
Open Communication
Recognize the growing demand for alternative training schedules and maintain open communication about this option to maximize awareness. Indicate in your Web site and other materials available to resident applicants that you are willing to consider part-time residencies to enable potentially interested residents/applicants to open the conversation. Proactively identify residents who may benefit from part-time training to optimize planning and implementation and to minimize resident stress.
Experimentation
Experiment with different schedules to benefit individual residents and define best practice, being mindful of guiding principles of GME and patient care. Define specific curriculum requirements and competencies. Embrace technology allowing for flexible attainment of these goals and institute objective measures for monitoring progress toward them.
Advocate
Advocate within the department and hospital for improved funding to cover additional costs that may arise when making part-time training financially feasible for residents (eg, benefits for part-time residents and/or extended paid family leaves). GME committees may be of assistance when presenting these issues at a national level.
Although complex in initial implementation, part-time residencies will meet a growing demand for alternative training options among medical school graduates and early-career pediatricians. Our ability as a profession to provide this option will allow us to meet our goals of attracting and maintaining a talented workforce, and promoting the health of all families.
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FOOTNOTES |
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Accepted Jun 6, 2007.
Address correspondence to Mary Beth Gordon, MD, Children's Hospital Boston, Department of Medicine, 300 Longwood Ave, Boston, MA 02115. E-mail: marybeth.gordon{at}childrens.harvard.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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