The latest iteration of the Residency Review Committee Program Requirements mandates the preparation of residents for the role of child advocate in the community.1 The Ambulatory Pediatric AssociationEducational Guidelines for Residency Training in General Pediatrics provides a blueprint for a community-based rotation, with goals, objectives, and suggested sites.2 In the current issue, Shope and associates share their experience with the construction of a community-based rotation for residents.3The structure of the rotation appears to reflect the design described in the Ambulatory Pediatric Association guidelines, thereby contributing real-world experience to confirm the value of the recommendations. The report also illustrates that a blueprint is only a blueprint; construction also requires bricks, mortar, knowledgeable individuals to direct the work, and a considerable amount of effort by workers.
The bricks, the components that make up the rotation, are the individual community sites. The authors from two neighboring programs pooled their contacts and resources to develop a greater richness of sites than might otherwise have been available. This is a useful strategy worth highlighting, because institutions are likely not to have such associations established for other resident rotations. For programs without another pediatrics residency nearby, an alternative might be a family medicine program in their institution that has ties to the community.
The mortar that keeps the components together is the preparation of and feedback from all parties: residents, community faculty, program faculty, and coordinators. Preparation goes beyond planning the rotation, articulating specific goals and objectives, and working out a schedule—although these are all critically important. Preparation also includes “priming” the residents for the cultural milieu of the community sites. This principle seems obvious for residents who take international rotations,4 but, in many instances, the community sites may be “foreign” to the experience of many residents. Likewise, the community site must be primed for the arrival of the resident. One of us recalls vividly the sense of embarrassment when, after his enthusiastic discussion of the benefits of residents being in the community, he was asked by a nonphysician, “What's a “resident'”? Through prerotation discussion and ongoing faculty development, the educational benefit of the experiences can be maximized.
It is possible for such a rotation to be carried initially by the enthusiasm of the parties involved, eager for what seems like a good idea: getting out of the hospital into the communities in which children are living and are being served. For success to be sustained, knowledgeable, credible faculty need to be identified and recruited, both in the community and in the program; faculty development may be valuable to enhance their effectiveness with residents. A notable feature of the report by Shope and associates is the sustained interest and activity by the residents, who maintained contact with the community sites and undertook projects with faculty assistance. The continued donation of time by community faculty and program faculty cannot be taken for granted, however. Anecdotally, some of the programs that have developed advocacy initiatives for residents are reporting faculty “burnout” after a few years of mentoring residents or groups of residents. The quantity and quality of faculty time and expertise need to be monitored, with some method of reinfusing energy if it dissipates.
In addition to faculty effort, there is considerable administrative work required to coordinate such a rotation, which Shope and associates estimate to equal the efforts of one FTE. Where does this work (time, energy, and money) come from? Again, Shope and associates turned to collaboration as a strategy. In these days of cost-containment, collaboration and shared effort are vital.
Finally, it is important to recognize that the rotation is not an end in itself, but a means to an educational and clinical end. Whether residents will, in fact, be able to advocate for children in the community as a result of such a rotation is not answerable by short-term evaluations. Shope and associates encourage us by noting the continued involvement and the various projects that have been generated. Community rotations currently must be considered promissory notes, work in progress. The outcomes of real interest are still a few years off.
- ↵Residency Review Committee for Pediatrics. Program Requirements for Residency Training in Pediatrics. Chicago, IL: Accreditation Council for Graduate Medical Education; 1996
- ↵Ambulatory Pediatric Association. Educational Guidelines for Residency Training in General Pediatrics. McLean, VA: Ambulatory Pediatric Association; 1996
- ↵Shope T, Bradley B, Taras H. A block rotation in community pediatrics. Pediatrics. 1999;104:143–147. Supplement
- ↵Torjesen K, Mandalakas A, Kahn R, Duncan B. International child health electives for pediatric residents. Arch Pediatr Adolesc Med. In press
- Copyright © 1999 American Academy of Pediatrics