Graduate medical education is in a period of transformation. This article reviews the state of pediatrics residency training by summarizing the changing demographics within training programs, examining the new educational paradigm with an emphasis on competency-based education and continuous professional development, and describing forces influencing the workplace and the focus on work-life balance. Strategies are suggested for leaders in graduate medical education to meet the challenges experienced during this period of transformation.
Pediatric residency training programs are enmeshed in a complex, fragmented, and changing health care system. The following important contextual changes of pediatric care provide challenges to the educational process of pediatrics residency training:
The explosion of new basic knowledge, particularly in the areas of genomics, proteomics, and neuroscience, developmental biology, and translational research have created clinical advances in diagnosis and therapy. However, the complexity of the interaction between genetics and social and environmental influences has compounded the challenge of clinical education of pediatric residents.1
The pattern of pediatric care for sick children is changing with a substantial increase of acuity and complexity of illness in hospitalized children, often requiring clusters of subspecialists and advanced technology to provide quality care. Chronic medical conditions are a much larger part of pediatric care as antibiotics and vaccines have brought many common infections of childhood under better control.2 Furthermore, children with more common disorders requiring hospitalization are having shorter hospitalizations. For many children, significant diagnostic and treatment activities go on before and after hospitalization in ambulatory settings, raising the acuity and demands of care in the community.
There is a medical need and an increasing public demand for implementation of quality-improvement programs both at the level of the institutions in which care is provided and the level of the individual physician-patient interface.3 The complexity and fragmentation of the large (macro) health system and the perfusion of smaller (micro) systems within hospitals and other institutions providing medical care, as well as the need for greater economic efficiency, have provided added impetus to the quality-improvement movement. Within health centers that train residents, quality-improvement activities must encompass residents and their supervising attending physicians, in addition to other professionals and staff, to be effective at the institutional level.4
It is within this context of the delivery of pediatric care that we discuss the current state of pediatric residency training by examining 1) current trends and the demographics of training programs in pediatrics, 2) the transformation of the educational continuum with a focus on outcomes and self-directed learning, and 3) the transformation of the workplace with the emphasis on work-life balance. It is our intent to benchmark the state of training at the cusp of the new millennium as a basis for comparison in the decades to come.
Through the efforts of the resident tracking program of the American Board of Pediatrics (ABP) and the Third Year Resident Survey of the American Academy of Pediatrics (AAP), detailed data are available to track enrollment and certification in general pediatrics and pediatric subspecialties and to observe trends in training and the job market.5,6 The ABP conducts data collection with the assistance of program directors by a thorough tracking system, including data from candidates sitting for their first certification examination and residents at the time of the In-Training Examination, which provides accurate data with nearly complete ascertainment. The AAP Third Year Resident Survey relies on self-report and is somewhat limited by the recall bias of its survey methodology, variable response rates from year to year, and inconsistent times of response to the survey. The information derived from these data sources does not allow precise assignment of causation for changes in pediatric enrollment and career choices; however, other observations and conclusions can be made. Four areas to be addressed here are: the total numbers of residents completing US training programs; the proportion of graduates who are women; the numbers entering general pediatrics versus subspecialty training; and the percent of residents coming from US or international backgrounds.
Starting in 1994, substantial increases in pediatric residency enrollment were seen in the data collected by the ABP. The rapid increase in enrollment reached a slowly rising plateau of ∼2900 first-time certification examination takers from 1998 through 2003. The percentage of women selecting a career in pediatrics has increased steadily for over a decade to just >70% of American medical graduates (AMGs) by 2003. More than half of residents in combined internal medicine and pediatrics programs are now women. Although women have traditionally been much less likely than men to choose a pediatric subspecialty career, there is a recent increase in the number of women planning subspecialty careers. The ABP In-Training Examination data for 2003 indicate that, for the first time, a majority of residents entering fellowship (54%) were women, and the number of first-year fellows taking In-Training Examinations has risen to its highest level (1006).
In 1986, 32% of all pediatric residency program graduates entered pediatric subspecialty training (eg, cardiology) and an additional 8% entered nonpediatric specialty training (eg, anesthesiology, neurology). Figure 1 graphically depicts the trends of career choice for pediatric subspecialties and nonpediatric specialties from 1986 to 2003. During this interval, perhaps buoyed by changing gender balance and economic forces such as the increase in managed care, the percentage of pediatric residency program graduates entering general pediatrics reached a peak of 73% in 1998. As of 2003, 65% of graduates now indicate that they are planning a career in general pediatrics. The proportion of residents in pediatric programs who are AMGs and international medical graduates follows an inverse pattern, reflecting the selection of international medical graduate candidates when there is less interest in pediatrics by AMG applicants. The percentage of AMGs enrolled in pediatric residency programs peaked at almost 83% in 1999 and was 76.5% in 2003. These data indicate that we are far from being able to attract sufficient numbers of US seniors to fill residency positions available in accredited US programs, and few interested seniors are unable to find US pediatric training positions.
The results of the AAP Third Year Resident Survey add some important additional information. These surveys are completed by >70% of a random sample of 500 third-year residents each year (∼1 in 6 graduating pediatric residents). During the period from 1997 to 2003, the percentage of underrepresented minority trainees increased from 6% to 12%. These data also reveal improved self-ratings of residents' quality of residency training in preparation for pediatric fellowship, child advocacy, and assessing needs of the community as it relates to child health. The authors suggest that exposure to community pediatrics during residency may account for the latter 2 trends. A sobering note is the increased individual indebtedness of residents, which grew from $64 070 in 1997 to $87 539 in 2002, an increase of almost 37%, whereas starting salaries for pediatricians during this interval were reported to have declined in 2002 dollars, from $103 161 in 1997 to $99 123 in 2002.
These demographics imply significant challenges for pediatric graduate medical education. Although the demography of pediatric graduate medical education in the United States is much more uniform than that reported in Europe, our demographic pattern rests on an unstable foundation of a complex, fragmented, and changing health care system.7 Workforce needs are difficult to predict, particularly with an unpredictable health care future. Therefore, in the face of continuing controversy about physician workforce needs and the uncertainty about how pediatric care will be delivered in the future, the pediatric graduate medical education community will need to monitor this situation carefully.8 Although clearly there are large markets with decreased need for new general pediatricians, there are many unmet opportunities in general pediatrics. In particular, there is also a notable maldistribution of pediatricians, with significant needs remaining in both urban and rural America.
Despite an increase in the total number of trainees and the number of women choosing subspecialty careers, significant variations exist among subspecialty fields in total numbers of trainees and the proportion of women within each field. Academic pediatricians have expressed concern about who will be the future physician-scientists in pediatrics, especially given the proportion of women training in pediatrics and the historical gender differences in selecting subspecialty fields.9
There are major barriers to recruitment of the best, brightest, and most motivated students to choose pediatrics as a career. Strategies must include addressing work-life balance and flexibility in training and career participation, given the increasing prevalence of women in the pediatric workforce, and the need to create a better work-life balance for all resident graduates. Pediatric programs will need to lead this effort within graduate medical education and create workable solutions that address family leave, part-time training and employment, child care availability, and managing educational debt. Pediatric educators and pediatricians will need to take an active role in helping to shape public opinion as a driving force to promote any needed legislative and regulatory changes.
TRANSFORMATION OF THE EDUCATIONAL CONTINUUM: FOCUS ON OUTCOMES AND SELF-DIRECTED LEARNING
The approach to the new millennium was heralded by the Institute of Medicine (IOM) report “To Err is Human—Building a Safer Health Care System,” which approximates a loss of 98 000 lives annually in this country secondary to medical errors.10 This report validated ongoing public outcry regarding problems in the health care system. In response to the concerns raised by the public and to address the need to inform legislators and governing bodies about the impact of graduate medical education on errors and quality of care, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) partnered to initiate what is known as the Outcomes Project.11 The essence of this project is a shift to a learner-centered, competency-based system of education driven by the desired outcomes of training. Thus, by 2006, the ACGME requires that all graduating residents demonstrate competence in the following 6 domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The more recent IOM reports “Crossing the Quality Chasm: A New Health System for the 21st Century” and “Health Professions Education: A Bridge to Quality” support the necessity of a major reform in education that will facilitate improvements in the health care delivery system and also align medical education with the desired health outcomes.3,12 Suggested areas of focus to accomplish this alignment include: patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. The similarities between the IOM areas of focus and the elements of the 6 ACGME competencies are striking.
Although the major focus of this shift to competency-based education has been at the level of graduate medical education, the Association of American Medical Colleges and the member boards of ABMS, including the ABP, are working with the ACGME to extend the focus on competence across the educational continuum, capturing both medical students and practicing physicians.13 The Association of American Medical Colleges Medical School Objective's Project outlines 4 domains of competence to be achieved by graduating students: knowledge, clinical skills, altruism, and dutiful behavior.14 When one breaks down the elements of these domains, they overlap significantly with the elements of the ACGME general competencies. Likewise, the ABP is shifting from a process of “recertification” to “maintenance of certification,” highlighting not only the traditional knowledge competency but also competencies in professionalism, continuous professional development (CPD), and practice improvement as prerequisites for maintaining certification in pediatrics.
Concurrent with this focus on competencies, leadership within pediatrics formed the Future of Pediatric Education II Task Force to envision the restructuring of education necessary to meet the needs of infants, children, and youth in the 21st century. Thirty-four recommendations emerged from the task force report, many of which echo the themes presented in the ACGME and IOM competencies, such as care within the context of family and community, collaboration with families and other health professionals, and individual learning plans for residents that will transition them from learning during training to life-long learning.15 In addition, the task force urges us to “take steps to enhance the scientific foundation of pediatric medical education and ensure that its programs (curriculum, teaching, and evaluation methods) are based on this science.”15 They advocate for the establishment of “research centers for pediatric medical education” to continuously evaluate impact of training on outcomes.
Transformation of Accreditation Requirements: The Focus on Outcomes
One has only to explore the recent literature that describes our inability to make accurate assessments of a trainee's competence to realize that change is necessary. In a study of the Observed Structured Clinical Examination (OSCE), Joorabchi and co-workers16,17 demonstrated the gap between expected performance and true performance of senior residents with only 4% of senior residents in good academic standing passing the minimum threshold set by the faculty for a passing score. Similar results were found in a study of auscultation skills of both residents and fellows in which a gap between expectations based on overall faculty perceptions of competence and actual performance is demonstrated.18 The evidence for positive impact of competency-based education on cognitive and functional outcomes of trainees is limited to date. One study of surgical residents, however, suggests that a competency-based instructional module for teaching invasive procedures reduced failure and complication rates, translating into a reduction in the time it took residents to resuscitate trauma victims in real practice.19 Despite the limited evidence in favor of competency-based education, the well-documented problems with our current system of medical education and health care delivery should motivate us to initiate and evaluate innovations that seem likely to improve care and educational outcomes.
The challenge to us as educators and professionals has been defined: to focus on outcomes, both clinical and educational, that in turn inform the provision of health care and the educational process. Only through the practice of evidence-based education can we positively impact the ultimate outcome of our educational efforts: the quality of health care delivered to our patients. Measuring outcomes requires a change in both philosophical approach and methods. Snadden20 summarizes this point well: “At present our assessment methods stem from the reductionist philosophy that underpins our discipline, and we are, thus, trapped by our need to compare like with like. Until we can make a mental shift that allows us to include a more holistic approach to assessment, one which values the development of individuals over time, we will continue to struggle to measure the unmeasurable, and may end up measuring the irrelevant because it is easier.”20 A case in point is the need to create ways of teaching and evaluating 2 of the 6 ACGME domains of competence, practice-based learning and improvement and systems-based practice, neither of which have held a place in traditional medical school or residency training curricula. The other 4 domains of competence have traditionally been evaluated by a single global tool that attempts to capture an assessment of patient care skills, medical knowledge, ability to communicate, and professionalism all in a 1- to 2-page generic form that often contains Likert-style questions, whereby evaluators rate resident performance on a numerical scale. Most programs have designed evaluation forms to meet individual program needs, and the reliability and validity of these measures have not usually been studied. Global ratings as sole evaluative tools have inherent errors: namely, rater errors such as leniency or severity, range restriction or central tendency of raters, and correlational error of the halo effect in which a rater gives similar evaluations to separate aspects of performance or even in several different evaluations.21 Although there is still a place for global ratings, the philosophical underpinnings of competency-based education, in addition to the inherent problems with global assessments, preclude their use as solo evaluation tools. To evaluate competence, one needs to directly observe and assess learners performing the tasks of real world future practice. This calls for “authentic assessment,” defined by Snadden and Thomas22 as “assessment that looks at performance and practical application of theory.”22 Another important underpinning of the evaluation of competence is the use of criterion-referenced assessment as opposed to norm-referenced assessment. In criterion-referenced assessment, the learner's performance is compared with a predetermined threshold or standard as opposed to the peer comparison of norm-referenced assessment.23 Thus, competencies must be defined with appropriate benchmarks and performance standards set in terms of thresholds.
As substrate for future development of evaluation strategies, the ACGME provided an initial workbook of evaluation methods, the Toolbox of Assessment Methods, for guidance.11 Suggested methods of evaluation included the following: record reviews, chart-stimulated recall, checklists of observed behaviors, global ratings, standardized patients, OSCEs, simulations and models, 360-degree assessments, portfolios, multiple-choice examinations, procedure logs, case logs, and patient surveys. With the exception of the OSCE, the reliability and validity of which have been demonstrated, other methods need additional development for practical application and subsequent study of their reliability and validity within the clinical setting.24 In the experience of the Outcomes Project thus far, the ACGME has identified 4 tools that are used most frequently and are expected to continue to be the main tools used in the near future: 1) direct observations with a checklist; 2) 360-degree evaluations; 3) educational portfolios; and 4) cognitive tests, eg, In-Training Examinations. The latter is the only 1 of the 4 that has been tested in standardized versions for validity and reliability.
It is clear that increased faculty time and resources will be required to implement competency-based evaluation of trainees. Review of the literature suggests that this evaluation process is best accomplished by using a portfolio infrastructure.22,25–35 Use of a portfolio allows for a collection of evidence that supports and documents the attainment of the 6 ACGME competencies. A few articles refer to the utility of a Web-based system for portfolio assessment, but these studies are limited by the narrow spectrum of the tools contained within the portfolio.36–40 A Web-based system, however, provides a user-friendly venue for compiling the variety of evidence needed to document all required competencies. It has the potential to improve the efficiency in using faculty time and resources. A national infrastructure for a Web-based portfolio may be the most effective way to expand the breadth and depth of portfolio assessment by studying the tools that are developed and piloted in the process. Establishing such a project will allow us to develop “best-practice” models that can be shared among program directors.
In accordance with the ACGME shift to a competency-based system of education, the pediatric Residency Review Committee incorporated minimal language to address the 6 competencies into the requirements for residency training, with expanded language planned for the next iteration, which is currently in draft form. The new requirements will be written in a format that will begin to take us from the more restrictive guidelines of the structure-and-process–based system to the more flexible guidelines of a competency-based system. The focus will be on outcomes of training within the 6 domains of competence and on the evidence that will be required to demonstrate how programs insure the attainment of competence for their trainees. There will be suggested methods for documenting this evidence, which will allow the program director to work toward the goal of developing methods that will provide “best evidence” within the given program.
Transformation in Certification: The Focus on Self-Directed Learning and Practice Improvement
The ABMS has not only partnered with the ACGME in promoting competence as the outcome of graduate-level training but is taking a major leap toward ensuring the competence of practicing pediatricians. The focus for practicing physicians will change from “recertification” to “maintenance of certification.” This shift is analogous to the shift from traditional continuing medical education to CPD, the latter being a more comprehensive model for learning: continuing medical education connotes a passive experience in which the learner attends a didactic seminar delivered by an expert. In some instances, the seminars are chosen by the learners, but many times the learners attend a seminar series such as grand rounds in which there is a prepared menu of conferences that may or may not be relevant to their own practice. CPD requires physicians to become active rather than passive learners and to make choices about their venue for learning (ie, on-line, reading, face-to face presentation) and the specific content of the learning needed to improve individual practice. Sectish et al41 highlight the critical importance of CPD in insuring the competence of practicing pediatricians and describe the Schön model of learning as the underlying premise behind CPD. In this model, learning is not merely an activity that results from “reflection in action” (the acquisition of “just-in-time” information to address an immediate need in the clinical setting) but also includes “reflection on action,” a process of learning in which one addresses the acquisition of knowledge that will lead to change in practice and practice improvement.42
The practicing physician will no longer be able to use demonstrated knowledge alone as both the necessary and sufficient criterion for recertification. The process will now include evidence of professional standing as well as evidence of one's commitment to life-long learning and satisfactory performance in practice. The ABP has outlined a 4-step process to achieve this goal. Step 1 requires the pediatrician to hold a valid medical license. Step 2 requires a demonstration of one's commitment to life-long learning by completing the on-line Knowledge Self-Assessment module on the ABP Web site or by participating in the AAP on-line version of the PREP Self-Assessment. A passing score on another on-line resource from the ABP, the Decision Skills Self-Assessment, will also be required as a component of step 2. Step 3 is the successful completion and attainment of a passing score on an examination of knowledge in a secure testing site. Step 4 requires analysis of one's practice by peer and patient surveys and demonstration of a practice improvement activity. The latter requirement can be satisfied by completion of the AAP on-line program called eQIPP (Education in Quality Improvement for Pediatric Practice). The phase-in of these 4 steps for general pediatricians will be complete by 2010, at which time all pediatricians with time-limited certificates that expire in 2010 and beyond will be expected to complete all 4 components to maintain their certification in pediatrics. A similar model is being developed for maintenance of pediatric subspecialty certification.
Computer technology allows for a practical approach to the maintenance of certification in a cost-effective manner, with a realistic time commitment and effort required. In addition, it has opened up a world of opportunities for those not inhibited by the challenge of learning how to use it. As a community of practice, we should maximize our use of technology and embrace the concept of a Web-based learning and evaluation portfolio that is initiated at entry into medical school and carried throughout the lifetime of one's career.
One of the greatest barriers to implementation of a competency-based system of education is that it requires each of us to change how we think and how we practice. For some, change is harder than it is for others. However, new requirements of accrediting and certifying organizations such as the ACGME and the ABP, respectively, will be instrumental in forcing change where it would not have happened otherwise.
For leaders in education ready to embrace the change, the greatest challenge in the shift to a competency-based system of education is faculty development and the resources to provide it. To promote an educational process that focuses on clinical and educational outcomes, with self-directed practice-based learning as the process for achieving the desired outcomes, we must have both academic and community-based faculty role models that implement these principles as a habit of practice. During this time of transition, we are in the difficult position of having to learn as we teach. This challenge presents us with an opportunity to look beyond our own specialties and partner with those in other disciplines, because ACGME competencies cross all disciplinary lines.
Another challenge is to create a vision of medical education that spans the continuum. No longer can we afford to function in the silos of undergraduate, graduate, and continuing medical education. The attainment and maintenance of competence for the practicing physician means that graduate medical education must be driven to provide the outcomes desired for a practicing professional, and in turn our students must graduate medical school equipped with the requisite entry-level competencies for residency training. We are fortunate to have leadership of the Association of Pediatric Program Directors (APPD) and the Council on Medical Student Education in Pediatrics entering into discussions on entry-level competencies for students interested in pediatric residency training. Likewise, the relationship between the APPD and the ABP will allow us to facilitate the transition from the resident to the practicing pediatrician.
Finally, we must meet the challenge of studying the impact of educational interventions and assessment methods with the same rigor that we use to address clinical and basic science issues. If we value the practice of evidence-based medicine, education deserves no less; we need to move in the direction of evidence-based education.43 Lack of formal training in evaluating educational outcomes is a barrier that we must overcome. A first step is to embrace the IOM competencies that we expect of our learners. By working in interdisciplinary teams and maximizing technology, we will provide the learning environment needed to improve, in parallel, the quality of our training programs and the care delivered to patients. The outcomes of this educational/clinical research, in turn, must inform how we should be training residents and may require a future reassessment of the length of training.15 An initiative spearheaded by the Chair of the Pediatric Education Steering Committee of the Federation of Pediatric Organizations (FOPO) to look at a redesign of residency training has the study of the links between educational and clinical outcomes as one of its goals.
TRANSFORMATION OF THE WORKPLACE: THE FOCUS ON WORK-LIFE BALANCE
The workplace of a residency program is a complex and intense environment. Long hours of continuous work, responsibilities of caring for sick patients, and increasing complexity and acuity of patient care in hospitals are realities of the current workplace in pediatric residency training programs.44 The work environment of decades ago, when current faculty and leaders in pediatric graduate medical education were themselves in training, has changed. In some children's hospitals today there are more intensive care beds than general medical-surgical beds. Daily activities of pediatric residents have changed: tasks such as starting intravenous lines are now performed by other members of patient care teams. Teams in hospitals are interdisciplinary, less hierarchical, and comprised of skilled professionals who share clinical responsibilities and rely on each other's unique skill sets. Therefore, communication skills, teamwork, and professionalism are as basic to residency training now as technical and clinical skills. Coordination of care for these acute and complex patients requires that physicians in training understand how to work within systems and assume professional roles on teams with other providers to address the broad range of patient and family needs. It is not uncommon for patients to have multiple consulting services contributing to their care, thus posing an educational challenge for trainees who must acquire the skills of thinking independently and making clinical decisions. New duty-hour standards have called into question issues such as commitment to patients and continuity of care, despite the lack of evidence that there has been any substantial change in the work ethic of current trainees. Complexity of patient care, significant responsibility, teams of professionals with specialized knowledge, the challenge to learn independent decision-making in a team environment, and new duty hours: these aspects of the contemporary workplace of residency provide a context in which the issues of work-life balance emerge as an important topic in the lives of physicians in training.
A 1998 survey of all medical interns found certain factors adding to the difficulties within the workplace of residency programs.45 Interns from all specialties reported a moderate level of satisfaction with the intern year; however, residents also reported a high rate (53%) of perceived mistreatment, ie, public humiliation or belittlement, by more senior residents on >3 occasions during internship. In addition, 63% of female interns and 15.3% of male interns reported at least 1 incident of sexual harassment. Among pediatrics interns, incidents of sexual harassment were the lowest (47.8%) but still surprisingly high. Another survey of internal medicine interns found high rates of burnout (76%) and an associated self-report of suboptimal patient care.46 These data are concerning and require us to address quality issues in the workplace to optimize the learning environment despite its complexity and intensity. The likelihood that working conditions may detrimentally impact the quality of patient care is particularly disturbing. All who are involved with pediatric graduate medical education must ensure that our training programs are consistent with the values we espouse as pediatricians and strive to continue to make a career in pediatrics attractive to outstanding medical student applicants.
Recently, the FOPO proposed a model for the 21st century pediatrician that could be applied to pediatric residents and provide direction for improving the workplace of pediatric residency:
“Twenty-first century pediatricians are professionals who are dedicated to making a difference in the lives of infants, children, and adolescents. They find joy and pride in serving the needs of children in the context of family and community. They have learned to provide comprehensive care for children, and are committed to providing culturally effective patient-centered care, informed by contemporary scientific knowledge.
They partner with patients and families in making high quality health care decisions, incorporating an understanding of the multi-factorial issues influencing child health. They routinely assess the quality of care they and the care team deliver, and lead efforts to improve care at the level of the patient, population, and health care system. They value balance in their lives and are committed to ongoing personal and professional development.”47
Several elements of this model have already been incorporated into training programs and others are among the major initiatives of the strategic plan of APPD.48 In this section we address duty hours, family and medical leave, and part-time residency and flexible options, which are potential targets for transforming the workplace, accommodating family life, and optimizing work-life balance.
For years, residency training has been synonymous with long hours of work. The name itself, “resident,” harkens back to the days when trainees resided within hospitals. Over the past several decades, the frequency of night call gradually decreased from every second and every third night to every fourth night but still resulted in resident work weeks that exceeded 90–100 hours on some resident rotations. Recently, the IOM raised national awareness of the occurrence of medical errors and the need for improved quality of systems of medical care, including the methods by which we train physicians.3 Although the link between medical errors and fatigue is still mostly assumed, the ACGME responded to public concerns and the IOM report by establishing new duty-hour standards in 2003 for all residency training programs to reduce sleep deprivation among trainees in the hope of not only improving the well-being of trainees but also minimizing medical errors.49,50 These standards set a limit of 80 hours per week for all residency programs and a maximum of 24 hours of continuous on-call duty, allowing an additional 6 hours to transfer care, debrief, and attend educational conferences. Pediatric residency programs, in contrast to other nonsurgical specialties, ranked sixth in total duty hours (before the new duty-hours standards) after general surgery, pediatric surgery, obstetrics and gynecology, neurologic surgery, and thoracic surgery and therefore have been impacted significantly by these new standards.51 Reductions in duty hours will likely result in a more humane working environment, but it is unclear how these improvements in duty hours will impact resident stress and burnout, patient care quality, and the quality of the training experience. Implementation of these standards will have far-reaching impacts on academic institutions and staffing within them and, perhaps, require a reengineering of both the systems of care and the systems of training.52,53 Residency program directors have an important obligation during this transition period to measure the impact of the changes on educational outcomes of residency training, and they should do so with the same scholarly rigor applied to other research endeavors.54 Career satisfaction, burnout, stress, and work-life balance must be studied as educational outcomes and as potential correlates with quality of patient care. Faculty, already burdened by increased demands for clinical and research productivity, cannot easily accommodate shifts of work to them as a result of improvement of resident duty hours or working conditions. Institutions, under increasing financial constraints, may be forced to find a replacement workforce at a much higher cost when work formerly done by residents cannot be shifted to faculty and subspecialty trainees.
Family and Medical Leave
Family and medical leave is a legal right that is subject to individual variation according to state law. Furthermore, each institution sponsoring a residency program is mandated to enforce family and medical leave policies according to ACGME institutional requirements. Some residents would prefer to extend their family and medical leave beyond what is allowable under state law or institutional policy. In general, pediatric residency programs have very limited flexibility to accommodate a reduction of residents in rotation schedules for family and medical leave, especially requests for extended leave. Some programs have created flexible options that allow residents to extend family and medical leave and extend time in training.55 The AAP 1995 policy statement on family and medical leave56 articulates important issues regarding parental leave and residency training: 1) departmental policies are often unclear and confusing and, as a result, may cause considerable anxiety; 2) the resident expecting a child often faces resentment from colleagues for the extra work that prolonged absences entail; 3) absences not planned in advance adversely affect the work schedules of peers; 4) morale problems among residency groups may be exacerbated by strategies that are used to replace or cover absent residents; and 5) inconsistencies in departmental policies within and among programs can cause discord.
A recent literature review of pregnancy during residency emphasized the importance of anticipating pregnancies and developing well-defined, written leave policies to support residents and families.57 The author suggested that such program practices that “allow flexible rotations while maintaining appropriate patient coverage” are more likely to “reduce residents' resentments and gender conflict.” Difficulty in implementing leave policies is related in large part to the dependence on residents for staffing hospitals to provide patient care. Institutions sponsoring training programs have recently looked to alternative providers such as hospitalists and allied health professionals to fill gaps in service created by new duty hours. This trend prompted by duty-hour reductions may have the unanticipated impact of creating greater flexibility within programs and could provide for more options to accommodate family leave or extended training. Such changes in the way care is provided, however, may also have an impact on opportunities for resident learning, and their impact should be monitored closely for both improvement in the work environment and possible limitations in learning opportunities.
Equally important to the need for providing policies and practices within training programs is the need to provide role models for young pediatricians in training. For pediatric practitioner role models, an AAP survey provides a perspective: among primary care pediatricians in practice, although 55% agreed that it was important to discuss parental leave with parents, only 16% reported actually discussing the topic, with a greater percentage of female pediatricians (24%) discussing the topic than male pediatricians (8%).58 Also, practitioners varied considerably in their own practice of taking family and medical leave, with women more frequently than men opting for family and medical leave (92% vs 45%) and taking longer periods of leave (67 vs 14 days). Understanding the reasons for these variations and gender differences are important in mentoring pediatric trainees and setting expectations for residents as they progress in their careers so that they can make informed decisions about starting families and achieving work-life balance.
Part-Time Residency and Flexible Options
Articles about part-time residency training have been present in the literature for >30 years. In 1969, Weinberg59 reported on the perspective of 14 subspecialty boards about part-time residency: at that time, the majority of subspecialty boards considered the request for part-time training on an individual basis and only 4 medical centers reported part-time programs in place outside of the field of psychiatry. Noting the growing number of women in medicine that might seek part-time residency if the option existed, the potential inconveniences experienced by sponsoring institutions, and unknown impacts on continuity of patient care and learning, the author called for a pilot program to evaluate educational and clinical outcomes associated with part-time residency training.
Since this report, there has been limited impetus for residency programs to offer flexibility in training or part-time residency options. Kamei et al55 at the University of California, San Francisco, developed a flexible option for pediatric residents to allow trainees to extend their training to raise a family or pursue related professional interests. A large residency program such as that offered by the University of California, San Francisco, offers more flexibility in scheduling to accommodate this option. In their report of their 10-year experience with the flexible option, 24 of 284 residents took advantage of the flexible option, in which residents after the first year may schedule out block periods of time for personal or professional reasons and extend their training for the length of time that they are away from the residency program. Salary and benefits are only in effect when residents are participating in the residency schedule, except for those on family and medical leave, for whom health benefits are continued. Flexible option participants were interviewed (21 of 24) and indicated that the flexible option was either critical (57%) or very helpful (43%) to their success as a resident. Eighty-eight percent of a sample of other residents in the program during 2001–2002, with 42 of 72 responding, agreed or strongly agreed that the flexible option should continue to be offered in the program. Although more pediatric residency programs now offer part-time or shared options to allow individuals to extend training to accommodate personal needs, family leave, or other interests, the majority of programs still do not offer part-time positions.
Within pediatric practice there is a steady increase in pediatricians who practice part-time: during the period from 1993 to 2000, an AAP survey showed that the percentage of pediatricians working part-time rose from 11% to 15%, with 24% of women and 4% of men working part-time.60 Among third-year pediatric residents polled in the same AAP survey, interest in part-time practice exceeded prevailing practice patterns in 2000, with 58% of female residents and 15% of male residents reporting a significant interest in seeking a part-time position. Practices will need to adapt to these changes in the workforce, both in terms of hiring and the operations of the practices. The adaptations may include improved communication and collaboration, with more use of technology. We also need to anticipate over the long-term that many of the part-time practitioners today may desire to expand their roles to full-time in the future. Tracking these trends will be important in determining workforce needs within pediatrics.
Within academic medicine, a similar dilemma exists. Given the preference for part-time employment among graduating senior residents and the few formal opportunities for part-time fellowship training or part-time faculty positions, it is unclear whether these limited options pose a barrier for the career selection of pediatric subspecialties and nonpediatric specialties. For residents who wish to pursue an academic career, medical school and department policies and practices must also be made more flexible to facilitate the entrance of more trainees into the complete spectrum of pediatric careers. The trends that were discussed earlier in this article (increasing women in pediatric training and increasing desire to work part-time) have implications for the recruitment of physician scientists and future academic pediatricians.
Leaders of pediatrics residency education programs and subspecialty residency (fellowship) programs must address issues of work-life balance to achieve 2 objectives of the Pediatric Education Steering Committee of the FOPO: 1) to make pediatric residencies and fellowships more responsive to family needs, especially steps that will promote the recruitment of women into the full range of pediatric career opportunities; and 2) to recruit talented medical students and residents into the broad spectrum of pediatric careers.61 Achieving the first objective will require cooperation and agreement among pediatric faculty and those who control the funding of graduate medical education to promote programs for addressing duty hours, family leave, and adequate and affordable child care. Solutions will vary considerably from institution to institution. Perhaps, in the language of Malcolm Gladwell, some early adopters will be needed as role models and thought leaders to achieve the “tipping point” toward establishing work-life balance in pediatric residency programs across the country.62 As the discussion about work-life balance proceeds, it cannot be limited to trainees. Faculty workload and satisfaction need to be assessed during this transition period of graduate medical education. Enhancing the work environment will also require a thorough evaluation of the function of teams, may necessitate reengineering of systems of care, and will likely involve faculty development to accomplish the broad goal of enhancing work-life balance for residents.
Over the past 3 years, data from the National Resident Matching Program indicate that students are choosing fields of medicine offering certain advantages such as higher income or better lifestyle. Concomitant with this change, fewer medical students are choosing primary care fields such as family medicine. Although pediatrics has been least impacted by this trend, leaders in pediatric graduate medical education must continue their efforts at program improvement to ensure that the number of pediatric practitioners, subspecialists, scientists, advocates, and teachers continues to meet the health care needs of our nation's children. Improving work-life balance within a program provides a training environment in which the next generation of pediatricians can thrive. Faculty and institutions must seize the opportunity to enhance residency training and assure that programs can recruit outstanding young trainees who not only value their professional endeavors but maintain a commitment to their personal life and values.
The tension created by external forces compelling a shift to a competency-based system of education and, at the same time implementing restricted duty hours, both in the name of quality care, through better education and training, requires careful reflection and creative intervention. The response must occur in the context of a changing health care delivery environment, explosion of new knowledge, exponential increase in the acuity and complexity of patient care, and a changing pediatric workforce demographic. We suggest these 5 strategies to meet the challenges facing pediatric graduate medical education in 2004:
Benchmark and refine workable solutions for family leave, part-time training, child care, and managing educational debt
Develop partnerships among stakeholders in medical education so that we may speak with 1 voice to effect the changes needed at institutional, state, and national levels to support graduate medical education in an era of escalating needs and scarce resources
Direct resources to support and educate faculty during this transition period at a time when they are being required themselves to learn a new system for their own maintenance of certification
Implement systems that promote self-directed learning and improvement, making this concept a reality across the educational continuum from medical school to the practice of medicine
Study the impacts through rigorous research and link educational outcomes with patient outcomes
We in pediatrics can and should take the leadership role in creating a community of learners that not only espouses but balances personal and professional life. Building a training infrastructure with a foundation that is learner centered and based on the 6 ACGME competencies and a care delivery system that is patient centered and based on the IOM competencies will enable the pediatric community to train the pediatrician of the 21st century to provide for the optimal health and well being of our children.11,12 It is time to take on the challenges ahead.
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- ↵American Board of Pediatrics. Available at: www.abp.org/stats/WRKFRC/Menu1.htm. Accessed July 21, 2004
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- ↵Association of Pediatric Program Directors. Mission statement. Available at: www.appd.org. Accessed October 1, 2003
- ↵Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on resident duty hours. 2002. Available at: www.acgme.org/DutyHours/wkgroupreport611.pdf Accessed March 11, 2003
- ↵Accreditation Council for Graduate Medical Education. Statement of justification for the final approval of common standards related to resident duty hours. 2002. Available at: www.acgme.org/DutyHours/impactStatement.pdf. Accessed March 11, 2003
- ↵American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care, Resident Section. Parental leave for residents and pediatric training programs. Pediatrics.1995;96 :972– 973
- ↵Cull WL, Mulvey HJ, O'Connor KG, Sowell DR, Berkowitz CD, Britton CV. Pediatricians working part-time: past, present, future. Pediatrics.2000;109 :1015– 1020
- ↵Pediatric Education Steering Committee. Objectives. Available at: www.fopo.org/OBJECTIVES.htm. Accessed September 27, 2003
- ↵Gladwell M. The Tipping Point. Boston, MA: Little, Brown and Company; 2000
- Copyright © 2004 by the American Academy of Pediatrics