Training in community pediatrics: a national survey of program directors.

OBJECTIVE: To describe the spectrum of residency training in community-based settings, assess the extent of resident education on community pediatrics topics, and determine whether educational activities vary by program size or availability of primary care tracks. METHODS: Survey of US pediatric residency program directors from May-September 2002. A 10-item self-administered questionnaire assessed the programs' extent of resident involvement in 15 selected community-based settings and inclusion of didactic or practical education regarding 13 community health topics. RESULTS: Of 168 programs surveyed (81% response rate), 40% were small (< or =30 residents), 35% were medium (31-50 residents), 25% were large (>50 residents), and 15% had primary care tracks. Frequently required community-based settings included schools (69%), child protection teams (62%), day care centers (57%), and home visiting (48%). Of 15 community-based settings, 28% required involvement in fewer than 4, 41% required involvement in 4-6, and 31% required involvement in 7 or more. More than two-thirds offered didactic teaching and practical experience on issues related to managed care, cultural competency, and the mental health and social service systems. There were no differences in the number of required community-based settings by program size or presence of primary care tracks. CONCLUSIONS: Most pediatric residency programs require exposure to community-based settings and provide education on various community health topics. Ongoing challenges include continued implementation amid work duty hour limitations, best practice models for practical implementation of community-based experience into residency training, and the impact of such training on future involvement in the community and physician practice.     

Residency Exposures and Anticipated Future Involvement in Community Settings

ObjectiveTo assess how exposures to community activities in residency impact anticipated future involvement in community child health settings.MethodsProspective cohort study of pediatric residents from 10 programs (12 sites) who completed training between 2003 and 2009. Residents reported annual participation for ≥8 days in each of 7 community activities (eg, community settings, child health advocacy) in the prior year. At the start and end of residency, residents reported anticipated involvement in 10 years in 8 community settings (eg, school, shelter). Anticipated involvement was dichotomized: moderate/substantial (“high”) versus none/limited (“low”). Logistic regression modeled whether residency exposures independently influenced anticipated future involvement at the end of residency.ResultsA total of 683 residents completed surveys at the start and end of residency (66.8% participation). More than half of trainees reported ≥8 days' of involvement in community settings (65.6%) or child health advocacy (53.6%) in residency. Fewer anticipated high involvement in at least 1 community setting at the end of residency than at the start (65.5% vs 85.6%, P < .001). Participation in each community activity mediated but did not moderate relations between anticipated involvement at the start and end of residency. In multivariate models, exposure to community settings in residency was associated with anticipated involvement at end of residency (adjusted odds ratio 1.5; 95% confidence interval 1.2, 2.0). No other residency exposures were associated.ConclusionsResidents who anticipate high involvement in community pediatrics at the start of residency participate in related opportunities in training. Exposure to community settings during residency may encourage community involvement after training.     

A block rotation in community health and child advocacy: improved competency of pediatric residency graduates.

CONTEXT: Despite increasing recognition of the importance of community health and child advocacy activities by pediatricians, residency programs have had little experience providing this education. There are no known reports examining the effects of such training on residency graduates. OBJECTIVE: To determine whether a program for educating residents in community health and child advocacy, Pediatric Links With the Community (PLC), improved attitudes and competencies of residency graduates. DESIGN: Survey of all graduates of the Rochester Pediatric Residency Program from 1991-2001. Graduates before institution of PLC (pre-PLC) were compared with graduates after institution of PLC (post-PLC). PARTICIPANTS: A total of 137 (81%) of 169 graduates participated; 78 (85%) of 92 were in the pre-PLC group and 59 (77%) of 77 were in the post-PLC group. INTERVENTION: PLC provides all pediatric residents with a 2-week rotation working with multiple community-based organizations. OUTCOME MEASURES: Differences between pre-PLC and post-PLC graduates in self-reported attitudes and competencies in multiple community health and child advocacy activities on 4-point Likert scales. RESULTS: The pre-PLC and post-PLC groups' attitudes toward community health activities were equally positive (3.4 vs 3.5, P =.08). The post-PLC group rated its competency higher in 8 of 12 activities (P <.05); its overall rating of competency was also higher (2.8 vs 2.3, P <.001). CONCLUSIONS: Although all pediatricians surveyed had positive attitudes toward community health and child advocacy activities, those who participated in PLC had higher self-perceived competency in most activities. Residency training programs can increase graduates' competence in community health skills.     

Residency training and use of strategies to promote community child health one year after graduation

ObjectiveTraining pediatricians to understand child health in the context of community and to develop skills to engage with community organizations remain priorities for residency education in the United States. Our objectives were to: 1) determine use of strategies to influence community child health by graduates of the Community Pediatrics Training Initiative (CPTI); and 2) to identify personal, practice, and residency program factors associated with use of strategies 1 year after residency.MethodsAnalysis of data from the Dyson Initiative National Evaluation included surveys of physicians (“graduates”) 1 year after residency and surveys of CPTI program leaders. Graduates reported personal and practice characteristics and use of one or more strategies to influence community child health. Chi-square and logistic regression were used to examine associations between personal, practice, and programmatic factors with use of strategies.ResultsOf the 511 graduates (68% participation), 44% reported use of one or more strategies. After adjusting for residency site, time spent in general pediatrics, and program emphasis on individual level advocacy, we found that graduates were more likely to report using strategies if they felt responsible for improving community child health (adjusted odds ratio [aOR] 4.1, 95% confidence interval [95% CI] 2.5–6.9), had contact with a person who provides guidance about community pediatrics (aOR 1.8, CI 1.2–2.6), or trained in a program that places great emphasis on teaching population level advocacy skills (aOR 2.3, CI 1.3–4.2).ConclusionsPersonal perspectives and residency education influence community involvement, even early in pediatricians’ careers. Efforts are needed to understand how content and delivery of training influence community engagement over time.     

A new, experiential curriculum in child advocacy for pediatric residents.

OBJECTIVE: To design, implement, and evaluate an experiential child advocacy curriculum for pediatric residents. DESIGN: Pilot study including before-after 2-group trial of an educational intervention and a qualitative component. SETTING: A large, hospital-based, urban resident continuity clinic. PARTICIPANTS: General pediatrics residents (N = 29 [PGY: 1-4]). INTERVENTION: Residents and faculty designed a longitudinal curriculum in child advocacy for the continuity clinic, which included community-based and legislative experiences for individual residents as well as clinic-based group activities. Residents reported their experiences to their clinic group at weekly preclinic conferences. In addition, residents presented posters at their year-end residency retreat and wrote grants to fund community projects based on their original findings. EVALUATION: We used a quantitative assessment of child advocacy knowledge, attitudes, skills, and self-reported practices, which residents completed pre- and postintervention (2 clinics) or, for comparison residents, at the beginning and end of the academic year (3 clinics). In addition, we conducted focus-group discussions with residents in the 2 intervention groups to explore unanticipated responses to the new curriculum. RESULTS: Residents who received the intervention (n = 13) had a greater increase in advocacy knowledge (2.62 vs 0.19, P =.005), ability to identify community resources (0.62 vs 0.16, P =.03), self-reported advocacy skills (2.0 vs -0.21, P =.002), and perceived value of advocacy training (0.31 vs -0.19, P =.03) compared with residents who did not (n = 16). In focus groups, intervention residents (n = 17) reported being surprised by community groups' and legislators' responsiveness to resident inquiries, and they expressed enhanced confidence in engaging these groups in dialogue about child policy issues. CONCLUSIONS: A longitudinal continuity clinic-based curriculum in child advocacy had significant positive impact on pediatric residents.     

Toward the development of advocacy training curricula for pediatric residents: a national delphi study.

BACKGROUND: Training in child advocacy is now required in pediatric residency program curricula. No national consensus exists regarding the content of such advocacy training. OBJECTIVE: To identify an operational definition of advocacy, as well as knowledge, skills, and attitude objectives for advocacy training in pediatric residency programs. METHODS: Professionals experienced in pediatric advocacy and training (n = 53) were invited to participate in a sequence of surveys to define the content of a pediatric residency advocacy curriculum that would result in acquisition of appropriate knowledge, skills, and attitudes related to advocacy for children. Three rounds of surveys were distributed, collected, and analyzed using a modified Delphi technique, in which the results from an antecedent survey were used to refine responses in a subsequent survey. RESULTS: Participants (n = 36), comprising a group of experienced leaders with diverse training and experience in child advocacy and resident education, created a consensus definition for advocacy. They initially identified 179 possible objectives for advocacy curricula. Through the iterative process of the Delphi technique, 32 of those objectives were identified as necessary for inclusion in a child advocacy curriculum for pediatric residents. CONCLUSIONS: Using a modified Delphi technique, a group of experienced leaders in pediatric advocacy were able to reach consensus on an operational definition of child advocacy and a set of objectives for a resident advocacy curriculum. Programs may use these findings to assist in developing an advocacy curriculum based on their own faculty assets and community resources.     

The training of pediatric residents in the care of acutely ill and injured children

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.     

Pediatric Resident Training in the Community Hospital Setting: A Survey of Program Directors

Background and ObjectiveThe role of a hospitalist differs in a community hospital (CH) compared to a university/children's hospital. Residents are required to practice in a variety of relevant clinical settings, but little is known about current trends regarding pediatric resident training in different hospital settings. This study explores CH rotations including their value for resident training, characteristics, benefits, and drawbacks. This study also seeks to define “community hospital.”MethodsAuthors conducted an online cross-sectional survey of pediatric residency program directors distributed by the Association of Pediatric Program Directors. The survey was developed and revised based on review of the literature and iterative input from experts in pediatric resident training and CH medicine. It assessed residency program demographics, availability of CH rotations, value of CH rotations, and their characteristics including benefits and drawbacks.ResultsResponse rate was 56%. CH rotations were required at 24% of residency programs, available as an elective at 46% of programs, and unavailable at 48% of programs. Residency program directors viewed these rotations as valuable for resident training. CH rotations were found to have multiple benefits and drawbacks. Definitions of “community hospital” varied and can be categorized according to positive or negative characteristics.ConclusionsResident rotations at a CH provide valuable learning opportunities with multiple potential benefits that should be weighed against drawbacks in the context of a residency program's curriculum. There are many characteristics that potentially distinguish CH from university/children's hospitals.     

Community pediatrics: gender differences in perspectives of residents.

OBJECTIVE: The Future of Pediatric Education II Report affirmed the importance of providing resident education in community settings. Yet we know little about related experiences of trainees and whether experiences and perspectives regarding community involvement vary by gender. We assessed gender differences in pediatric residents' involvement in and perspectives regarding community activities. METHODS: A national survey of US pediatric residents assessed residents' involvement in 14 activities before medical school and the intensity and perceived importance of involvement in 17 activities during medical school and residency. Expected future involvement 10 years hence was assessed for 11 community settings. chi2 and analysis of variance were used to examine bivariate relations by gender. Multivariate linear regression was used to model the relationship between gender and expected future involvement. RESULTS: Of the 700 respondents, 68% were women. Relative to men, more women reported exposure to child health advocacy and other community activities before and during medical school. Women and men reported similar involvement in residency, although women placed greater importance on inclusion of 16 of 17 community activities in their training. Female residents were more likely to report that current training in the community would influence their future career activities. Women anticipated greater future involvement in 6 of 11 settings. In adjusted analyses, gender remained associated with future involvement in 5 settings. CONCLUSIONS: As women come to comprise an increasing proportion of the pediatric workforce, further efforts are needed to understand the impact of gender on future involvement in community child health activities.     

Demographic features and attitudes of program directors of combined internal medicine and pediatrics residencies

Combined residency training in internal medicine and pediatrics has proliferated greatly in the last ten years. This survey of program directors (N = 55) of such residency programs reports their personal and professional demographic characteristics as well as their perceptions about aspects of combined training. The directors were more often affiliated with Internal medicine (33 directors [60%]), 47 (85%) were men, their mean age was 44 years, they had been out of medical school for a mean of 19 years, the mean time served as program director was 2.6 years, and 32 (58%) had completed a fellowship. The programs had existed for an average of 4.2 years, the mean entering class size was 2.8 persons, and the mean number of graduates per program was 4.2. We report directors' perceptions of why students choose combined training, why the programs have proliferated, and how these residents differ from family medicine residents. We comment on curriculum design and the goals of combined internal medicine-pediatrics residency training programs.     

Career counseling practices in pediatric residency training programs

Although there has been an emphasis on career satisfaction in pediatrics and on motivators that impact on resident career selection, little attention has been directed toward the career development process in pediatric residency training. This report summarizes the results of a survey conducted of 155 pediatric residency program directors about their counseling practices. Implications of the results and recommendations are discussed to improve this process.     

Residents as health advocates: The development, implementation and evaluation of a child advocacy initiative at the University of Toronto (Toronto, Ontario)

BACKGROUND AND OBJECTIVE:

Advocacy is an integral part of a paediatrician’s role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario).

METHODOLOGY:

Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents.

RESULTS:

Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback.

CONCLUSIONS:

Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.     

Combined internal medicine/pediatric residency training programs

Combined residency training in both internal medicine and pediatrics has become a popular choice for postgraduate education in the 1980s. Most programs are relatively new, and little is known about their specific curricular structure and what program graduates do when they complete their training. Data collected from a survey of these combined program directors are described.     

Training Pediatric Residents to Provide Parent Education: A Randomized Controlled Trial

ObjectiveWe evaluated the effect of Primary Care Positive Parenting Program (Triple P) training on pediatric residents and the families they serve to test 2 hypotheses: first, training would significantly improve resident skill in identifying and addressing discrete parenting and child behavior problems; and second, parents would report an improvement in their sense of self-efficacy, use of positive discipline strategies, and their child's behavior.MethodsStudy participants included pediatric residents from 3 community clinics of a pediatric residency program, as well as English-speaking parents of children aged 18 months to 12 years without a diagnosed behavior disorder cared for by study residents. Residents were randomized to receive Primary Care Triple P training either at the beginning or end of the study period. The measured resident outcomes were self-assessed confidence and skills in giving parenting advice. The measured family outcomes were parent sense of self-efficacy, child externalizing behavior, and discipline strategies.ResultsPrimary Care Triple P training had a positive, significant, and persistent impact on residents' parenting consultation skills (mean increase on Parent Consultation Skills Checklist 48.11, 95% confidence interval [CI] 40.07, 57.36). Parents visiting intervention-trained residents demonstrated improved disciplinary practices compared to parents visiting control residents (mean change in Child Discipline Survey 0.322, 95% CI 0.02, 0.71), with stronger differential effects for parents with lower baseline skills (mean Child Discipline Survey change 0.822, 95% CI 0.48, 1.83). No differences were found for child behavior or parenting sense of confidence.ConclusionsTraining residents in Primary Care Triple P can have a positive impact on consultation skills and parent disciplinary practices. This finding adds strength to the call for increased residency training in behavioral pediatrics.     

Residents as teachers in Canadian paediatric training programs: A survey of program director and resident perspectives

BACKGROUND:

The importance of the teaching role of residents in medical education is increasingly being recognized. There are little data about how this role is perceived within training programs or how residents develop their teaching skills. The aims of the present study were to explore the perspectives of Canadian paediatric program directors and residents on the teaching role of residents, to determine how teaching skills are developed within these programs, and to identify specific areas that could be targeted to improve resident teaching skills and satisfaction.

METHODS:

Program directors and residents in Canadian paediatric residency programs were surveyed about the scope of teaching performed by residents, resident teaching ability and resources available for skill development.

RESULTS:

Responses were received from 11 of 13 program directors contacted. Nine programs agreed to have their residents surveyed, and 41% of residents in these programs responded. Directors and residents agreed that residents taught the most on general paediatric wards, and that medical students and residents were the most frequent recipients of resident teaching. While 72% of directors reported that instruction in teaching was provided, only 35% of residents indicated that they had received such training. Directors believed that residents needed improvement in providing feedback, while residents wanted help with teaching at the bedside, during rounds and in small groups. Teaching performance was included in rotational evaluations in most programs, but residents were often uncertain of expectations and assessment methods.

CONCLUSION:

There is a general consensus that residents play an important teaching role, especially on the inpatient wards. Residents’ ability to fill this role could be enhanced by clearer communication of expectations, timely and constructive feedback, and targeted training activities with the opportunity to practice learned skills.     

Breastfeeding education and support services offered to pediatric residents in the US

ObjectiveThe American Academy of Pediatrics (AAP) encourages pediatricians to support the practice of breastfeeding and residency educators to develop formal curricula in breastfeeding education. Few studies, however, describe breastfeeding education or support services currently provided to pediatric residents in the United States. The goals of this study were to investigate breastfeeding training offered during 3-year pediatric residency programs and to describe residency programs’ policies and services for residents who breastfeed.MethodsWe conducted a cross-sectional study using a Web-based survey of pediatric program directors regarding breastfeeding education and support services for residents.ResultsSeventy percent of program directors (132 of 189) completed the survey, with 77.3% of respondents (n = 102) estimating the amount of breastfeeding education offered to their pediatric residents. Residents are provided with a median total of 9.0 hours of breastfeeding training over 3 years, primarily in continuity clinic and in lectures and rounds with attendings. At the programs’ primary teaching hospitals, breastfeeding residents are provided breastfeeding rooms (67.0%), breast pumps (75.3%), and breast milk storage facilities (87.6%). Only 10 programs reported having an official policy to accommodate breastfeeding residents.ConclusionsPediatric residents receive approximately 3 hours of breastfeeding training per year. In addition, there is less than universal implementation by residency programs of AAP recommendations for supporting breastfeeding in the workplace. Pediatric residency programs should find ways to improve and assess the quality of breastfeeding education and workplace support to better role model this advocacy standard.     

The status of academic general pediatrics: no longer endangered?

Our study objective was to assess the current state of general academic pediatrics in the United States. A confidential survey of division directors was conducted. At the beginning and end of the survey period, programs were called to verify the director's name. Of 199 divisions surveyed, 119 were returned. The number of physician and nonphysician division faculty has grown from a mean of 12.1 (+/-8.2) and 1.7 (+/-1.8), respectively, 5 years ago to 15.6 (+/-11.7) and 2.1 (+/-2.6). Over a 15- to 18-month period, 21% of programs had a change in division director leadership. Over 90% of divisions rated the clinical care and education missions as "very important," with research and advocacy thus rated by 29% and 50%. Ninety-five percent of divisions have primary responsibility for residency continuity clinics, 51% residency program, and 64% medical student clerkship. The mean number of annual outpatient visits was 29,821 (26,487). Academic general pediatrics divisions have grown and play a large role in clinical care, education, and research at their institutions. There is a need for continued focus on recruitment, fellowship training, faculty development, and leadership development. Although these divisions are now well established, many continue to feel "endangered" because of funding uncertainties in supporting their missions.     

How are pediatric training programs preparing residents for practice?

The majority of pediatric residents continue to choose a career in practice on completion of their training. Despite knowing residents' career preferences, many training programs have focused on inpatient tertiary care at the expense of primary care. Perhaps this reflects service needs and the significant technology and extensive information resulting in the growth of pediatric subspecialties. To determine the spectrum of didactic and clinical experiences pediatric training programs offer residents to prepare them for managing a practice, we conducted a survey of pediatric training program directors in 1988. Although the majority of residency programs have a practice management curriculum, the number of hours devoted to this area is minimal. In addition, a significant number of residents are not experiencing a community office rotation. This survey indicates the need to develop a practice management curriculum if trainees are to be prepared for choosing the right career and for being competitive in practice.     

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program

BackgroundEnvironmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees.ObjectiveDescribe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees.MethodsCareers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors.ResultsFifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed “environment” or “environmental” in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences.ConclusionsThe APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.