Postgraduate training in paediatrics: analysis of deficiencies as perceived by paediatricians

A listing of all general paediatricians in the country was obtained from the directory of members of the Australian College of Paediatrics. Each of the 287 paediatricians identified was sent a questionnaire requesting information about morbidity patterns of patients seen in their practices and their views regarding paediatric training. The response rate was 80.9%. Half the respondents had been in practice for 10 years or less, while two-thirds practised in a capital city. Respondents rated their training in each of 10 organic specialty areas, on average, as having been appropriate. However, when given a listing of nine areas related to child development and behaviour, chronic disease and counselling, 70% rated training in these areas as having been inadequate; this figure was even higher for recent graduates. Less than one-third had formal training in developmental, behavioural and community paediatrics; the remaining two-thirds of respondents acquired their knowledge by clinical experience, books or journals, professional contacts or meetings. This was despite the fact that almost 80% of respondents felt that practical experience was not an adequate substitute for formal training in developmental and behavioural paediatrics. There was an encouraging trend for paediatricians who had been in practice for 10 years or less to have had training in these areas, although the number was still less than half. Almost 90% of respondents felt that changes were needed in paediatric training to equip trainees for general paediatric practice, while 62% of respondents were of the opinion that the present FRACP training system mitigated against appropriate training for general paediatrics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Postgraduate training in paediatrics: Analysis of deficiencies as perceived by paediatricians

Abstract A listing of all general paediatricians in the country was obtained from the directory of members of the Australian College of Paediatrics. Each of the 287 paediatricians identified was sent a questionnaire requesting information about morbidity patterns of patients seen in their practices and their views regarding paediatric training. The response rate was 80.9%. Half the respondents had been in practice for 10 years or less, while two-thirds practised in a capital city. Respondents rated their training in each of 10 organic specialty areas, on average, as having been appropriate. However, when given a listing of nine areas related to child development and behaviour, chronic disease and counselling, 70% rated training in these areas as having been inadequate; this figure was even higher for recent graduates. Less than one-third had formal training in developmental, behavioural and community paediatrics; the remaining two-thirds of respondents acquired their knowledge by clinical experience, books or journals, professional contacts or meetings. This was despite the fact that almost 80% of respondents felt that practical experience was not an adequate substitute for formal training in developmental and behavioural paediatrics. There was an encouraging trend for paediatricians who had been in practice for 10 years or less to have had training in these areas, although the number was still less than half. Almost 90% of respondents felt that changes were needed in paediatric training to equip trainees for general paediatric practice, while 62% of respondents were of the opinion that the present FRACP training system mitigated against appropriate training for general paediatrics. Ninety-three per cent of respondents agreed that paediatricians had a major role to play in the management of children with problems of development and behaviour. Respondents made a large number of pertinent comments regarding perceived deficiencies in their training. These data are discussed in terms of the need to address imbalances in training. It is suggested that steps need to be taken to address the conflict between hospital service and training needs, that more trainees should be exposed to experiences in ambulatory and community settings, and that it is important to consider the introduction of appropriate curricula in developmental and behavioural paediatrics into Australian training programmes.     

Australian paediatricians and the new morbidity: A national survey of changing paediatric practice patterns

Abstract General paediatricians across Australia were surveyed to determine whether their practice reflected the commonly held assumption that paediatrics was changing, with an increased emphasis on ambulatory and community care and involvement with conditions comprising the new morbidity. A 10 page questionnaire was mailed to every paediatrician in the Australian College of Paediatrics directory of members considered to be practising general paediatrics. Of a total of 287 questionnaires distributed, 224 were returned (response rate 80.9%). Two-thirds of respondents practised in a capital city, while the remaining third were divided equally between isolated paediatricians and those who practised in a provincial city. Only 15 paediatricians (6.8%) spent more than half their time involved in inpatient care, while 60% spent less than one-fifth of their time with inpatients. There was no correlation between inpatient involvement and length of paediatric practice, but surprisingly there was a significant trend ( P = 0.007) for paediatricians practising in a capital city to do more inpatient work. Respondents were provided with a list of eight conditions held commonly to comprise the new morbidity, and there was a strong response indicating an increase in children seen with these conditions over the past 5 years, as well as a decrease in children with clearly identifiable organic disease. Furthermore, respondents indicated in absolute terms the numbers of patients seen in the past month with each of the conditions. Results confirmed the significant numbers of children seen with conditions comprising the new morbidity, their increased presentation to paediatricians in the past 5 years and the predominance of non-inpatient work in consultant paediatric practice in Australia.     

Survey on developmental-behavioural training experiences of Australian paediatric advanced trainees

In order to monitor whether paediatric education has adapted to meet modern practice 91 paediatric advanced trainees were surveyed to elicit their satisfaction with developmental-behavioural (DB) training. A response of 69% was obtained to a postal questionnaire. The traditional imbalance persists, with trainees considering themselves significantly better informed in the medical disciplines (P>0.001). Satisfaction with training in the 14 developmental disciplines surveyed is less (P>0.001) and significantly more variable compared with 11 traditional medical disciplines (P>0.01). Formal rotations in DB disciplines had been received by all respondents by the 7th year of training. However, 46–67% consider themselves ill-informed in learning/school problems, attention-deficit hyperactivity disorder, adolescent problems, paediatric rehabilitation and language impairment. Thirty-seven per cent found formal postgraduate instruction unhelpful. Paediatric advanced training gives exposure to, but unsatisfactory formal education, in developmental and behavioural paediatrics. Current initiatives for mandatory DB training have serious implications for achieving adequate resources and standards to meet clinical and training demands.     

The training paths and practice patterns of Canadian paediatric residency graduates, 2004–2010

BACKGROUND:The Paediatric Chairs of Canada have been proactive in workforce planning, anticipating paediatric job opportunities in academic centres. To complement this, it is important to characterize the practice profiles of paediatricians exiting training, including those working outside of tertiary care centres.OBJECTIVE:To describe the training paths and the practice patterns of Canadian paediatric residency graduates.METHODS:A survey was completed in 2010 to 2011 by Canadian program directors regarding residents completing core paediatrics training between 2004 and 2010. Data collection included training path after completing core paediatrics training and practice type after graduation.RESULTS:Of 699 residents completing their core training in paediatrics, training path data were available for 685 (98%). Overall, 430 (63%) residents completed subspecialty training while 255 (37%) completed general paediatrics training only. There was a significant increase in subspecialty training, from 59% in earlier graduates (2004 to 2007) to 67% in later graduates (2008 to 2010) (P=0.037). Practice pattern data after completion of training were available for 245 general paediatricians and 205 subspecialists. Sixty-nine percent of general paediatricians were community based while 85% of subspecialists were hospital based in tertiary or quaternary centres. Of all residents currently in practice, only 36 (8%) were working in rural, remote or underserviced areas.CONCLUSIONS:Almost two-thirds of recent Canadian paediatric graduates pursued subspecialty training. There was a significant increase in the frequency of subspecialty training among later-year graduates. Few graduates are practicing in rural or underserviced areas. Further studies are needed to determine whether these trends continue and their impact on the future paediatric workforce in Canada.     

The evolving role of community-based general paediatricians: the Barwon experience

OBJECTIVE: To detail the acute and chronic paediatric service and community-orientated activities and responsibilities of community-based general paediatricians. METHODOLOGY: Data were collected over the 12 months July 1996 to June 1997 relevant to (i) acute neonatology and paediatrics, (ii) the different community paediatric service organizations with which the paediatricians were involved, and (iii) the quantification of the amount of time spent in non-consulting paediatric work. RESULTS: Findings revealed decreasing hospital admissions, infrequent severe neonatal resuscitation requirements, extensive involvement in community organizations and a great deal of time spent in non-consulting paediatric work. CONCLUSIONS: Ongoing training and upgrading in acute paediatric diagnostic and procedural skills, rationalization of resuscitation expertise, training in management and administrative skills and models of care for the chronically ill should become part of the training of community-based general paediatricians.     

Paediatrician's role in caring for children with learning difficulties

Aim: Children with learning difficulties are commonly seen in Australian paediatric outpatient settings. The practice patterns of paediatricians in assessing, referring and managing these children are unknown, and there is no consensus on best practice. We thus aimed to examine the consistency between Australian paediatricians': (i) assessment; (ii) referral; and (iii) management of children presenting with learning difficulties. Methods: All 373 paediatrician members of the Australian Paediatric Research Network were invited to participate in an online survey in 2010. Paediatricians who saw children with learning difficulties were asked questions about their assessment, referral and management practices. Results: Of 181 (49%) paediatricians to complete the survey, 140 (77%) reported seeing patients with learning difficulties. Most often, paediatricians supplemented their clinical assessments with audiology assessments (75%), teacher or parent questionnaires (60–65%), or teacher contact (51%). Paediatricians used medical investigations (40%), direct assessment tools (27%) or a school visit (4%) less often. Most paediatricians referred children with learning difficulties to educational psychology (84%), special education (61%) or speech therapy (66%) services but less often to occupational therapy (34%) or mental health (15%) services. The most common management strategies were to provide a report to the school (76%) or parents (66%) and to make recommendations around sleep hygiene (75%) and for tutoring (66%). Conclusions: Australian paediatric practice in this area is diverse, with the greatest variability around management practices. These data provide a case for designing and implementing evidence‐based guidelines for the paediatric care of children who struggle to learn in school.     

Fine needle aspiration biopsy: diagnostic utility in resource-limited settings

BACKGROUND: Little information is available on the value of fine needle aspiration biopsy (FNAB) in routine paediatric practice in resource-limited settings. AIM: To provide an overview of all paediatric FNAB samples received at Tygerberg Hospital, Cape Town, South Africa over a 3-year period, including the determinants of sample adequacy and the diagnoses. METHODS: Samples were analysed from three locations: Tygerberg Hospital (TBH) where pathologists performed all the procedures, surrounding clinics where aspirates were mostly performed by doctors with no formal training in FNAB technique, and Queen Elizabeth Hospital, Blantyre, Malawi where FNABs were performed by trained nurse aspirators. RESULTS: A total of 830 aspirates were reviewed: 464 (56%) from TBH, 264 (32%) from local clinics and 102 (12%) from Blantyre. The main diagnoses at TBH were mycobacterial infection (31%), normal/reactive tissue (27%) and malignancy (14%); malignancy dominated (74%) in the select group from Blantyre. Sample adequacy rates were similar between pathologists and nurse aspirators [399/464 vs 82/102, odds ratio (OR) 1.4, 95% confidence interval (CI) 0.8-2.6]. Results were significantly better in the group who received formal training (TBH and Malawi) than in the clinics where clinicians had no formal training (481/566 vs 171/264, OR 3.1, 95% CI 2.2-4.4). CONCLUSIONS: FNAB provides a definitive tissue diagnosis in the majority of patients. Well-trained nurse aspirators perform as well as pathologists, indicating the feasibility of FNAB in resource-limited settings.     

Development and evaluation of a follow up assessment of preterm infants at 5 years of age.

BACKGROUND: Long term follow up shows a high frequency of developmental disturbances in preterm survivors of neonatal intensive care formerly considered non-disabled. AIMS: To develop and validate an assessment tool that can help paediatricians to identify before 6 years of age which survivors have developmental disturbances that may interfere with normal education and normal life. METHODS: A total of 431 very premature infants, mean gestational age 30.2 weeks, mean birth weight 1276 g, were studied at age 5 years. Children with severe handicaps were excluded. The percentage of children with a correctly identified developmental disturbance in the domains cognition, speech and language development, neuromotor development, and behaviour were determined. RESULTS: The follow up instrument classified 67% as optimal and 33% as at risk or abnormal. Of the children classified as at risk or abnormal, 60% had not been identified at earlier follow up assessments. The combined set of standardised tests identified a further 30% with mild motor, cognitive, or behavioural disturbances. The paediatrician's assessment had a specificity of 88% (95% CI 83-93%), a sensitivity of 48% (95% CI 42-58%), a positive predictive value of 85% (95% CI 78-91%), and a negative predictive value of 55% (95% CI 49-61%). CONCLUSIONS: Even after standardised and thorough assessment, paediatricians may overlook impairments for cognitive, motor, and behavioural development. Long term follow up studies that do not include detailed standardised tests for multiple domains, especially fine motor domain, may underestimate developmental problems.     

Australian paediatricians and the new morbidity: a national survey of changing paediatric practice patterns

General paediatricians across Australia were surveyed to determine whether their practice reflected the commonly held assumption that paediatrics was changing, with an increased emphasis on ambulatory and community care and involvement with conditions comprising the new morbidity. A 10 page questionnaire was mailed to every paediatrician in the Australian College of Paediatrics directory of members considered to be practising general paediatrics. Of a total of 287 questionnaires distributed, 224 were returned (response rate 80.9%). Two-thirds of respondents practised in a capital city, while the remaining third were divided equally between isolated paediatricians and those who practised in a provincial city. Only 15 paediatricians (6.8%) spent more than half their time involved in inpatient care, while 60% spent less than one-fifth of their time with inpatients. There was no correlation between inpatient involvement and length of paediatric practice, but surprisingly there was a significant trend (P = 0.007) for paediatricians practising in a capital city to do more inpatient work. Respondents were provided with a list of eight conditions held commonly to comprise the new morbidity, and there was a strong response indicating an increase in children seen with these conditions over the past 5 years, as well as a decrease in children with clearly identifiable organic disease. Furthermore, respondents indicated in absolute terms the numbers of patients seen in the past month with each of the conditions. Results confirmed the significant numbers of children seen with conditions comprising the new morbidity, their increased presentation to paediatricians in the past 5 years and the predominance of non-inpatient work in consultant paediatric practice in Australia.     

Jubilee Lecture of the Scottish Paediatric Society. Do we really need community paediatricians? A summary of the lecture given at the Triennial Meeting of the Scottish Paediatric Society

To summarise, I have supported the development of a specialty of "child development and rehabilitation" as an independent branch of paediatrics separate from neurology; emphasised the importance of expertise in child abuse for all paediatricians and not just those working in "the community"; described the changing role of specialist paediatric doctors in pre-school surveillance and the school health service; and suggested that we may need community paediatricians with a public health orientation. It is important to determine what community paediatricians should do and to ensure that the training they receive is relevant to the tasks required of them.     

Síndrome de burnout en pediatras con actividad asistencial en urgencias. Prevalencia y factores asociados. Análisis multinivel

IntroductionThe aim of our study was to describe the prevalence of burnout syndrome (BOS) in paediatricians working in paediatric emergency care settings and to analyse its association with potential risk factors.Material and methodsMulticentre cross-sectional study through a survey of paediatricians working in paediatric emergency care settings in hospitals affiliated to the Research Network of the Spanish Society of Paediatric Emergency Medicine (SEUP) between September 2019 and January 2020. We analysed the association between social/family-related, demographic, occupational and satisfaction factors and the presence of BOS by means of multivariate and multilevel mixed-effects logistic regression models.ResultsThe estimated prevalence of BOS was 36.5% (95% confidence interval [CI]: 31.7%-41.2%). In the multivariate analysis, lacking a stable group of friends (OR: 2.57; 95% CI: 1.10-5.97), problems in and out of the work setting (OR: 3.06; 95% CI: 1.60-5.88) and a work experience of 9 years or less (OR: 2.31; 95% CI: 1.37-3.90) were identified as individual factors that increased the risk of SBO, while feeling acknowledged by coworkers (OR: 0.48; 95% CI: 0.30-0.79) and acknowledged by one's supervisor (OR: 0.62; 95% CI: 0.41-0.93) were protective factors. In relation to the hospital, the paediatric emergency unit being a subdepartment of the Department of Paediatrics (OR: 3.81; 95% CI: 1.85-7.85), the presence of an on-call emergency medicine specialist around the clock (OR: 3.53; 95% CI: 1.62-7.73) and a volume of 28 or more paediatric emergency encounters a day to be managed per on-call physician (OR: 2.05; 95% CI: 1.01-4.16) were identified as independent risk factors for SBO. There was no variability in the prevalence of BOS attributable to differences between hospitals and autonomous communities, save for the described situations.ConclusionsThe prevalence of SBO among these providers is high. There are modifiable factors that we can intervene on to address BOS, independently of the hospital or region.     

Development and evaluation of a follow up assessment of preterm infants at 5 years of age

Background: Long term follow up shows a high frequency of developmental disturbances in preterm survivors of neonatal intensive care formerly considered non-disabled. Aims: To develop and validate an assessment tool that can help paediatricians to identify before 6 years of age which survivors have developmental disturbances that may interfere with normal education and normal life. Methods: A total of 431 very premature infants, mean gestational age 30.2 weeks, mean birth weight 1276 g, were studied at age 5 years. Children with severe handicaps were excluded. The percentage of children with a correctly identified developmental disturbance in the domains cognition, speech and language development, neuromotor development, and behaviour were determined. Results: The follow up instrument classified 67% as optimal and 33% as at risk or abnormal. Of the children classified as at risk or abnormal, 60% had not been identified at earlier follow up assessments. The combined set of standardised tests identified a further 30% with mild motor, cognitive, or behavioural disturbances. The paediatrician''s assessment had a specificity of 88% (95% CI 83–93%), a sensitivity of 48% (95% CI 42–58%), a positive predictive value of 85% (95% CI 78–91%), and a negative predictive value of 55% (95% CI 49–61%). Conclusions: Even after standardised and thorough assessment, paediatricians may overlook impairments for cognitive, motor, and behavioural development. Long term follow up studies that do not include detailed standardised tests for multiple domains, especially fine motor domain, may underestimate developmental problems.     

General paediatric practice in autism spectrum disorder screening in Ontario,Canada: Opportunities for improvement

BackgroundScreening is important for early identification of children with autism spectrum disorder (ASD), potentially leading to earlier intervention. Research has identified some barriers to early identification of ASD, however, information about ASD screening in Canadian general paediatric practice is lacking.ObjectivesThe aim of the study is to better understand ASD screening practice patterns by examining the use of ASD and general developmental screening tools by general paediatricians.MethodsThe research team conducted a cross-sectional survey of general paediatricians.ResultsTwo-hundred and sixty-seven paediatricians responded and 132 were eligible for the study. Ninety-three per cent of the responders used a developmental screening tool. Eighty-five per cent of the responders used an ASD screening tool when there were concerns for ASD, and 15% never used one. The most commonly used ASD screening tool was the M-CHAT. Children suspected of having ASD were referred to specialists not only to confirm the diagnosis but also to facilitate access to resources. General paediatricians were keen to incorporate formal ASD screening tools in their practice but identified the need for clearer guidelines.ConclusionPrevious studies have shown that children at risk of ASD continue to be missed through developmental surveillance and targeted screening. Paediatricians are interested in implementing an ASD screening tool and cite brevity and forms that can be completed by parents as factors that would support the use of a screening tool. Clearer guidelines and tools to support ASD screening and access to resources are needed.     

A comparison of paediatrics occupational therapy university program curricula in New Zealand, Australia, and Canada

Comparisons were made of the paediatric content of professional entry-level occupational therapy university program curricula in Australia, New Zealand, and Canada using an ex post facto survey methodology. The findings indicated that in Australia/New Zealand, paediatrics made up 20% of the total curriculum, but only 13% in Canada. Canadian reference materials were utilized less often in Canadian universities than in Australia/New Zealand. Theories taught most often in Australia/New Zealand were: Sensory Integration, Neurodevelopmental Therapy, Client-Centered Practice, Playfulness, and the Model of Human Occupation. In Canada, the most frequent theories were: Piaget's Stages of Cognitive/Intellectual Development, Neurodevelopmental Therapy, Erikson's Eight Stages of Psychosocial Development and Sensory Integration. The most frequently taught paediatric assessment tools in both regions were the Bruininks-Oseretsky Test of Motor Proficiency and Miller Assessment for Preschoolers. Paediatric intervention methods taught to students in all three countries focused on activities of daily living/self-care, motor skills, perceptual and visual motor integration, and infant and child development.     

Medical students�� views on selecting paediatrics as a career choice

Despite increasing numbers of UK medical students, the number of trainees selecting paediatrics as their specialty choice has decreased. Previous studies show that most students will choose their ultimate career during undergraduate training. We therefore explored the views of students in the final year at Birmingham University about a career in paediatrics. Students completed a 27-item questionnaire during the penultimate week of their paediatric clerkship (PC) and 97% responded (127/131). Prior to the PC, 29% (37/127) of students had considered a career in paediatrics, rising to 50% (63/127) after the PC (p < 0.001). Students felt that paediatricians were enthusiastic and keen on teaching, and the ward working atmosphere was good. However, students perceived paediatrics as a difficult specialty with high competition for training posts. Students felt their paediatric experience was too limited and advice was needed on paediatric careers early in undergraduate training. This study confirmed that focusing on improving the PC is not sufficient if we are to inspire medical students to consider a career in paediatrics. Exposure to the specialty is needed from year 1 of undergraduate training along with career advice to dispel current myths about specialty training. Students would then be able to make more informed career decisions.     

Diagnosis of autistic spectrum disorders in Queensland: variations in practice

OBJECTIVE: For both paediatricians and child psychiatrists, referrals to assess possible autistic spectrum disorders (ASD) are increasing. This study examines current practices of medical specialists in the assessment of these disorders. METHODS: An anonymous, self-report questionnaire was sent to all Queensland paediatricians and child psychiatrists. The survey elicited frequencies of consultation for ASD, diagnostic method, advice provided and perceived adequacy of training for this work. RESULTS: Responses were received from 79 (85%) eligible paediatricians and 26 (58%) eligible child psychiatrists. For one-third of all clinicians, new consultations for possible ASD occurred as often as 2-3 times per week. Most specialists approached the clinical diagnosis of ASD by considering history from different sources and professional assessments. Paediatricians (86%) were more likely than child psychiatrists (62%) to request genetic studies for children with severe autism (P = 0.01). Both general paediatricians and developmental paediatricians perceived level of training for possible ASD consultations was significantly worse than child psychiatrists (P < 0.001 and P = 0.02, respectively), but no difference was found between paediatric groups (P = 0.27). Perceived adequacy of specialist training was not associated with length of experience in clinical practice. CONCLUSION: Medical practice in Queensland around diagnosis of ASD is characterized by considerable variability. There is still a long way to go if we are to achieve consistency around medical issues of organic diagnosis and practices impacting on health as well as consideration of differential developmental diagnoses. The finding that recently trained paediatricians felt just as unprepared for this work as their older colleagues suggests that the graduate training response to this 'new morbidity' has not been adequate.     

A Comparison of Paediatric Occupational Therapy University Program Curricula in New Zealand,Australia, and Canada

Comparisons were made of the paediatric content of professional entry-level occupational therapy university program curricula in Australia, New Zealand, and Canada using an ex post facto survey methodology. The findings indicated that in Australia/New Zealand, paediatrics made up 20% of the total curriculum, but only 13% in Canada. Canadian reference materials were utilized less often in Canadian universities than in Australia/New Zealand. Theories taught most often in Australia/New Zealand were: Sensory Integration, Neurodevelopmental Therapy, Client-Centered Practice, Playfulness, and the Model of Human Occupation. In Canada, the most frequent theories were: Piaget's Stages of Cognitive/Intellectual Development, Neurodevelopmental Therapy, Erikson's Eight Stages of Psychosocial Development and Sensory Integration. The most frequently taught paediatric assessment tools in both regions were the Bruininks-Oseretsky Test of Motor Proficiency and Miller Assessment for Preschoolers. Paediatric intervention methods taught to students in all three countries focused on activities of daily living/self-care, motor skills, perceptual and visual motor integration, and infant and child development.