Recently Trained General Pediatricians: Perspectives on Residency Training and Scope of Practice
OBJECTIVE. Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training.
METHODS. A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4–5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1–2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice.
RESULTS. The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care.
CONCLUSIONS. The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.
The scope and manner of residency training and physician decision-making regarding career choice for pediatricians was last assessed systematically in 1995 as part of the Future of Pediatric Education II (FOPE II) Project.1 However, that project relied mostly on expert opinion and small-scale, limited research studies to assess nationally the then-current educational programs.2
Since the FOPE II Project, there have not been significant changes in the structure of pediatrics resident education. However, the prevalence of the types of patients encountered by pediatricians today is different from at the time of the FOPE II Project. Currently, pediatricians provide care to more children with chronic illnesses than in years past.3 In addition, new technologies have created the need for pediatricians to be aware of new genetic and other types of recently discovered illnesses and conditions.4
Because of the increase in both the prevalence and the complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. Furthermore, emphasis on cost containment and the shift to high-volume ambulatory pediatrics has increased focus on prevention, health maintenance, and treatment of “minor” acute illnesses. It is unknown how well prepared general pediatricians believe themselves to be for these roles after residency training.
This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training.
The American Board of Pediatrics maintains a database of all physicians who are certified as generalists within the field of pediatrics. The list includes all those who have ever applied for board certification and the years in which they applied. To characterize the strengths and weaknesses of residency training from the perspective of recently trained general pediatricians, we selected a random sample of 600 generalists whose initial application for general pediatrics certification occurred between 2002 and 2003 (4–5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1–2 years out of training).
In collaboration with the American Board of Pediatrics Research Advisory Committee and the Residency Review and Redesign in Pediatrics (R3P) Committee, we developed a structured questionnaire to be administered by mail. The survey contained 14 items and was designed to be completed in 10 minutes or less. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice. The questionnaire was a composite of fixed-choice and Likert-scale questions.
The first mailing of questionnaires was sent via priority mail to the 1200 physicians in the sample in August 2007. The survey packet contained a personalized, hand-signed cover letter, the instrument, a business reply mail envelope, and a $5 bill as an incentive to complete the questionnaire. Two additional mailings were sent to nonrespondents in September and October 2007. The second and third mailings were sent via first-class mail and contained a personalized cover letter, the instrument, and a business reply mail envelope.
First, frequency distributions were calculated for all survey items. Next, χ2 statistics were used to compare respondents according to gender and between respondents who indicated that they had local access to subspecialists with those who did not.
The study was approved by the University of Michigan Medical School Institutional Review Board.
Of the 1200 survey packets mailed, 103 were returned as undeliverable by the postal service, and 830 physicians returned the survey; this yielded an overall response rate of 76%. One hundred twenty-two respondents were ineligible because they were pursuing pediatrics subspecialty training or no longer working in the field of pediatrics.
On review of the data, 23 of the generalists were determined to be ineligible for the survey because they had completed residency training before 2002. These generalists were removed from the data analysis, which left a total of 685 respondents for analysis.
Respondent Characteristics and Practice Setting
Three fourths of the respondents were women (75% [n = 503]), and 15% (n = 104) were international medical graduates. More than half (55% [n = 377]) of the respondents described their current clinical practice as general pediatrics outpatient care with little or no inpatient care. Approximately one third (32% [n = 214]) of the generalist respondents described their current clinical practice as general pediatrics outpatient care with substantial inpatient care. More than half (55% [n = 375]) of the respondents reported their current clinical practice setting to be in private practice, 17% (n = 113) provide care in a community-based health center, and 15% (n = 101) work at an academic health center. A majority (83% [n = 570]) of the respondents practice in an area with local access to most of the pediatrics subspecialists they need (Table 1).
No meaningful differences were seen for any response among those who had completed residency training 4 to 5 years before the survey and those who completed training 1 to 2 years before the survey.
When asked to identify the 2 most important factors in selection of their specific residency program, generalists most commonly reported location (65% [n = 439]) and lifestyle or overall fit (40% [n = 270]). Approximately one third of the respondents indicated that subspecialty expertise or training opportunities (29% [n = 199]) and program prestige (28% [n = 189]) were the most important factors.
The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]) (Table 2).
Generalists were asked to report what they would have done differently if given 6 to 12 months of additional flexibility in their 3-year residency program. The largest proportion of respondents indicated that they would have added additional outpatient subspecialty care (59% [n = 400]) and additional outpatient general care (45% [n = 308]). Only 14% (n = 95) of the respondents reported that they would have added additional inpatient general or subspecialty care, and 9% (n = 60) reported that they would not have made any changes to their residency training experience.
Postresidency Career Choice
Thirty-seven percent (n = 250) of generalist respondents would have been more likely to choose a subspecialty if combined residency and subspecialty training were 5 years instead of 6. Approximately one third (32% [n = 219]) reported no desire to pursue subspecialty training.
When asked to identify the 2 most important factors in determining a postresidency career, generalists reported lifestyle (eg, work hours) (71% [n = 481]) and location (52% [n = 350]) most often. Overall, women were more likely than men to report structured hours or lifestyle as 1 of the 2 most important factors in their career choice; men were more likely than women to cite earning potential (Table 3).
Scope of Practice
Approximately half of the generalists reported that they routinely care for children who require subspecialty expertise in areas such as adolescent medicine (51% [n = 342]), developmental or behavioral pediatrics (47% [n = 315]), allergy or immunology (49% [n = 327]), dermatology (47% [n = 314]), and reading radiographs (52% [n = 351]). The majority of respondents reported that they never or rarely care for children who require subspecialty care in areas such as genetics (64% [n = 433]), rheumatology (74% [n = 495]), and critical care medicine (69% [n = 467]). Table 4 provides additional details on the frequency of patients requiring subspecialty expertise.
Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. This was most common for cardiology (87%), neurology (87%), endocrinology (86%), rheumatology (78%), and genetics (77%). More than half of the respondents indicated that they are comfortable managing adolescent medicine (75% [n = 499]) and dermatology (53% [n = 356]) patients without the assistance of a subspecialist. On the other hand, only a minority felt comfortable managing mental health (7%), sports medicine (30%), and developmental/behavioral pediatrics (31%) without the assistance of a subspecialist, which mirrors their desire for more training in those areas (Table 2).
Half (52% [n = 342]) of the respondents reported that they are uncomfortable participating in care for patients who require critical care. Approximately one fifth of general pediatricians reported that they are uncomfortable participating in the care of patients who require genetic (21% [n = 141]), hematology or oncology (24% [n = 163]), rheumatology (21% [n = 139]), or mental health (20% [n = 132]) subspecialist expertise. Table 5 provides additional details on the comfort level of generalists in managing patients who require subspecialty care.
Respondents who indicated that they did not have local access to subspecialists were more likely to report that they are comfortable managing patients than those who indicated that they did have such access: neonatology (25% vs 12%; P = .0003), adolescent medicine (85% vs 72%; P = .0118), pulmonary (50% vs 37%; P = .0194), dermatology (63% vs 51%; P = .0341), and sports medicine (44% vs 27%; P = .0009). Generalist respondents without local access to subspecialists were also more likely (38% vs 26%; P = .0047) to report being comfortable reading radiographs without the assistance of a subspecialist.
The most important finding from our study was that approximately half of the generalists reported that they could have used additional residency training in mental health, oral health, sports medicine, and developmental/behavioral pediatrics. This is consistent with the results of previous studies.5–7 It is also consistent with the descriptions of reasons for specialty and subspecialty referrals from general pediatricians reported by Forrest et al,8 who found that, taken together, orthopedic symptoms, behavioral problems, fractures, traumatic joint injuries, developmental delay, depression/anxiety/neurosis, and attention-deficit/hyperactivity disorder accounted for 21% of referrals. Referrals for oral health were not reported. Forrest et al also found that referrals occurred in 2.3% of office visits; thus, a busy pediatrician is likely to refer a child on an almost-daily basis. Thus, referral patterns provide further insight on where and how to make targeted improvements in residency training.
Although there have been opinions published regarding a “training-practice gap”9 between what residents are taught and what they need to be able to do once they are in practice, our findings show the difficulty with generalizations. We found that the respondents believed that they were trained adequately in most subspecialty areas. In contrast to other studies that focused on a specific clinical area and demonstrated perceived deficiencies, our questionnaire asked respondents to rate all subspecialty rotations and training areas, which allowed physicians to assess residency training as a whole.5,10–15 Although pediatricians found training to be adequate overall, specific shortcomings in residency training were noted for general pediatricians. A recent survey of pediatrics subspecialty fellows revealed a different pattern of perceived deficiencies,16 indicating that “one-size-fits-all” training may not be appropriate.
We specifically studied physicians who had recently completed training to reduce the possibility of recall bias associated with their assessment of residency training experiences. This was balanced with the need to study physicians who actually had some experience in caring for patients after their residency. Our study population was different from that of previous studies that attempted to assess some of the same issues. It was not limited to fellows of the American Academy of Pediatrics, a specific geographic region, or a single program. In addition, our response rate of >75% decreases the likelihood of significant response bias.
If given increased flexibility in their residency training, the majority of respondents would have added additional outpatient subspecialty care or outpatient general care.
It is of interest that two thirds of our respondents reported that they never or rarely care for children who require subspecialty care from a geneticist. It is likely that the increasing use of expanded newborn screening and the rapid rise in the private availability and use of genetic testing kits will result in greater demand for general pediatricians with a stronger knowledge base in this area and for a greater referral capacity from geneticists.17 Although there has been a significant amount written in the lay press regarding the availability and use of genetic screening and testing, there seems to be little impact on primary care providers thus far. Most (77%) stated that they feel comfortable comanaging patients with a geneticist, but 21% reported feeling uncomfortable participating in the care of a child who requires subspecialty genetic involvement.
There were several other subspecialty areas in which the majority of respondents reported that they never or rarely cared for patients, including rheumatology and nephrology. For some, this may suggest that the experience with these subspecialties should be only a minimal part of residency education. However, the issue of correspondence between experiences during residency and postresidency practice is larger than whether exposure to individual subspecialty disciplines is appropriate. A central responsibility of residency education is training for management or comanagement of problems that are new or unfamiliar. These could be problems for which training was unavailable in a particular residency program, problems for which training was available but not utilized, or problems or approaches to diagnosis and/or management that did not exist at the time residency education took place.
Unfortunately, for many pediatrics subspecialties there is also a paucity of subspecialists who can either provide such training or can act as consultants for their patients once out in practice.18,19 General pediatricians who practice in areas without local access to subspecialists for their patients were only slightly more comfortable managing patients with specific subspecialty-related conditions alone; this raises the issue of whether there should be more targeted training during residency in specific subspecialty areas for those who intend to practice in rural or other areas without easy subspecialty access.
Previous studies have asked respondents to list the reasons why they chose a specific residency program. These studies have uniformly provided unranked lists of reasons with several factors being named very frequently. To better define the relative importance of such factors, we asked our subjects to identify the 2 most important factors in their selection of residency programs. Interestingly, the 2 most commonly cited factors for residency program selection were the same as those in the selection of postresidency career choice: location and lifestyle. This consistency identifies a pattern of priorities for those who pursue generalist careers that precede their matriculation into residency training. This method of questioning also demonstrated that, in contrast to findings in other studies, earning potential, although important, is likely not the defining factor in such decisions.20–23
Although internal medicine requires only 2 years of fellowship training to become a subspecialist, pediatrics subspecialty training requires 3 years. This has been considered a contributing factor in the proportion of pediatricians who enter fellowship training. More than one third of our respondents reported that they would have been more likely to choose a subspecialty if combined residency and subspecialty training were 5 years’ long instead of 6. This finding has important implications in light of the relative shortage of pediatrics subspecialists.
The training of general pediatricians should be a dynamic process. As the nature and epidemiology of pediatrics care change, our educational system must change as well. The challenge has been and will continue to be to ensure excellence of care across a broad spectrum of clinical areas while preserving a measure of flexibility relative to the individual interests and needs of each trainee.
This work was funded by the American Board of Pediatrics Foundation.
We gratefully acknowledge the assistance of the Residency Review and Redesign in Pediatrics Committee and the project group in formulation of the research questions.
- Accepted September 22, 2008.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, 300 N Ingalls, Building 6E08, Ann Arbor, MI 48109-0456. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Task Force on the Future of Pediatric Education. The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century: a collaborative project of the pediatric community. Pediatrics.2000;105 (1):163– 212
- ↵Johnson RL, Charney E, Cheng TL, et al. Final report of the FOPE II Education of the Pediatrician Workgroup. Pediatrics.2000;106 (5):1175– 1198
- ↵Cunniff C; American Academy of Pediatrics, Committee on Genetics. Prenatal screening and diagnosis for pediatricians. Pediatrics.2004;114 (3):889– 894
- ↵Demorest RA, Bernhardt DT, Best TM, Landry GL. Pediatric residency education: is sports medicine getting its fair share? Pediatrics.2005;115 (1):28– 33
- Krol DM. Educating pediatricians on children's oral health: past, present, and future. Pediatrics.2004;113 (5). Available at: www.pediatrics.org/cgi/content/full/113/5/e487
- ↵Boreman CD, Thomasgard MC, Fernandez SA, Coury DL. Resident training in developmental/behavioral pediatrics: where do we stand? Clin Pediatr (Phila).2007;46 (2):135– 145
- Flaherty EG, Sege R, Price LL, Christoffel KK, Norton DP, O'Connor KG. Pediatrician characteristics associated with child abuse identification and reporting: results from a national survey of pediatricians. Child Maltreat.2006;11 (4):361– 369
- Guevara JP, Feudtner C, Romer D, et al. Fragmented care for inner-city minority children with attention-deficit/hyperactivity disorder. Pediatrics.2005;116 (4). Available at: www.pediatrics.org/cgi/content/full/116/4/e512
- ↵Sneed RC, May WL, Stencel CS. Training of pediatricians in care of physical disabilities in children with special health needs: results of a two-state survey of practicing pediatricians and national resident training programs. Pediatrics.2000;105 (3 pt 1):554– 561
- ↵Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA; Research Advisory Committee of the American Board of Pediatrics. Pediatric fellows: perspectives on training and future scope of practice. Pediatrics.2009;123 (1 suppl):S31– S37
- ↵Mayer ML. Are we there yet? Distance to care and relative supply among pediatric medical subspecialties. Pediatrics.2006;118 (6):2313– 2321
- ↵Pan RJ, Cull WL, Brotherton SE. Pediatric residents’ career intentions: data from the leading edge of the pediatrician workforce. Pediatrics.2002;109 (2):182– 188
- Copyright © 2009 by the American Academy of Pediatrics