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.     

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.     

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.     

Religion, spirituality, and depressive symptoms in primary care house officers.

OBJECTIVE: The arduous nature of residency training places house officers at risk for depression. We sought to determine the prevalence of depressive symptoms in pediatric (PED), internal medicine (IM), family medicine (FM), and combined internal medicine-pediatric (IMPED) house staff, and spiritual/religious factors that are associated with prevalence of depressive symptoms. METHODS: PED, IM, FM, and IMPED residents at a major teaching program were asked to complete a questionnaire during their In-Training Examination. Depressive symptoms were measured with the 10-item Center for Epidemiologic Studies Depression Scale. Independent variables included demographics, residency program type, postgraduate level, current rotation, health status, religious affiliation, religiosity, religious coping, and spirituality. RESULTS: We collected data from 227 subjects. Their mean (SD) age was 28.7 (3.8) years; 131 (58%) were women; 167 (74%) were white; and 112 (49%) were PED, 62 (27%) were IM, 27 (12%) were FM, and 26 (12%) were IMPED residents. Fifty-seven house officers (25%) met the criteria for having significant depressive symptoms. Having depressive symptoms was significantly associated (P< .05) with residency program type, inpatient rotation status, poorer health status, poorer religious coping, and worse spiritual well-being. In multivariable analyses, having significant depressive symptoms was associated with program type, poorer religious coping, greater spiritual support seeking, and worse spiritual well-being. CONCLUSIONS: Depressive symptoms are prevalent among house officers and are associated with certain residency program types and with residents' spiritual and religious characteristics. Identifying residents with depressive symptoms and potentially attending to their spiritual needs may improve their well-being.     

Factors influencing the choice of a residency training program. A student's perspective.

Current trends in pediatric residency training have shown that a growing number of programs have been unable to fill their available positions through the National Resident Matching Program, Evanston, Ill. This has caused a competitive climate among programs to attract medical students as potential residents. The purpose of this study was to learn what factors are important to all students in determining the rank order of the residency training programs to which they have applied. Analysis of data obtained from 600 survey respondents (40%) showed that program curriculum was most important. Factors, such as night call and benefits, took on much less importance. Differences did exist between students who applied for pediatric vs other residencies. The balance between primary and tertiary care and a university setting are examples of variables that had a greater influence on aspiring pediatricians. This information has important implications for training program directors.     

Part-time training in pediatric residency programs: principles and practices

Despite growing interest in part-time work, few pediatricians are pursuing part-time residency training. There is currently little guidance for programs or residents who wish to design an alternative path through residency. In this article we review the need for part-time residencies and address obstacles to be overcome in their initiation. Strategies are offered for residents and program directors planning part-time training pathways, with recommendations for implementation amid a changing environment for graduate medical education. The needs of trainees, residency programs, hospitals, and credentialing organizations are considered.     

Changes in pediatric residents' perceptions of their continuity experience during their training: a national study.

OBJECTIVE: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. METHOD: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. RESULTS: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. CONCLUSIONS: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.     

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.     

National trends in pediatric resident recruitment.

Primary care residency programs throughout the nation are having increasing difficulty recruiting sufficient residents. Only 65% of pediatric residency positions are filled with medical graduates from the United States. We sent a questionnaire to pediatric residency program directors throughout the country to assess what changes pediatric programs had implemented in response to matching concerns. Forty-one percent had recruited non-house officer professionals to perform resident-type work. Such professionals included osteopathic and/or foreign-trained physicians (55%) and moonlighters (49%). House staff work hours had been reduced in 35% of programs and on-call frequency in 33%. Sixty-one percent had made significant changes in their recruiting practices in the past 5 years that are described herein. Annual recruiting budgets varied from nothing to over $75,000. This survey reveals widespread reduction in resident work load and increased intensity in the recruiting process throughout the country.     

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.     

The pediatric program director. An analysis of the role and its problems

A questionnaire designed to elicit information about the work environment, knowledge, and stresses of pediatric residency program directors was mailed to the 235 member programs of the Association of Pediatric Program Directors (APPD). At the time that the 187 respondents (80% return rate) assumed responsibility for their training programs, many rated their knowledge of various aspects of residency program administration as "poor." The respondents indicated that a lack of time, the pressures of too many other academic responsibilities, and a fear of not "filling" all positions in the National Intern Matching Program created much personal stress. Most program directors felt that educational conferences designed to teach educational methods, and administrative skills, and provide technical information knowledge necessary for residency program supervision would be beneficial.     

Community pediatrics: a consistent focus in residency training from 2002 to 2005.

OBJECTIVE: To assess changes in community pediatrics training from 2002 to 2005. METHODS: Pediatric residency program directors were surveyed in 2002 and 2005 to assess resident training experiences in community pediatrics. Program directors reported on the following: provision of training in community settings; inclusion of didactic and practical teaching on community health topics; resident involvement in legislative, advocacy, and community-based research activities; and emphasis placed on specific resources and training during resident recruitment. Cross-sectional and matched-pair analyses were conducted. RESULTS: A total of 168 program directors participated in 2002 (81% response rate), and 161 participated in 2005 (79% response rate). In both years, more than 50% of programs required resident involvement with schools, child care centers, and child protection teams. Compared with 2002, in 2005, more programs included didactic training on legislative advocacy (69% vs 53%, P < .01) and offered a practical experience in this area (53% vs 40%, P < .05). In 2005, program directors reported greater resident involvement in providing legislative testimony (P < .05), and greater emphasis was placed on child advocacy training during resident recruitment (P < .01). CONCLUSIONS: In the last several years, there has been a consistent focus on legislative activities and child advocacy in pediatric residency programs. These findings suggest a strong perceived value of these activities and should inform efforts to rethink the content of general pediatric residency training in the future.     

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.     

Look Who's Talking: A Survey of Pediatric Program Directors on Communication Skills Education in Pediatric Residency Programs

ObjectiveTo determine current practices for communication skills curriculum and assessment in pediatric residency programs and to identify programs’ greatest needs regarding communication curricula and assessment.MethodsWe surveyed pediatric residency program directors about their programs’ approach to teaching and assessing residents’ communication skills and how satisfied they were with their curricula and assessment of competence. Respondents were asked about their programs’ greatest needs for teaching and assessing communication skills.ResultsResponse rate was 41% (82/202). Most programs did teach communication skills to residents; only 14% provided no formal training. Programs identified various 1) educational formats for teaching communication skills, 2) curricular content, and 3) assessment methods for determining competence. Many programs were less than satisfied with their curriculum and the accuracy of their assessments. The greatest programmatic need regarding curricula was time, while the greatest need for assessment was a tool.ConclusionsWhile teaching and assessment of communication skills is common in pediatric residency programs, it is inconsistent and variable, and many programs are not satisfied with their current communication training. There is need for development of and access to appropriate and useful curricula as well as a practical tool for assessment which has been evaluated for validity evidence.     

Management of the febrile child: a survey of pediatric and emergency medicine residency directors.

We conducted a survey to determine whether there is uniformity in the training of residents regarding the management of febrile children. One hundred forty-three (62%) of 231 pediatric and 39 (53%) of the 73 emergency medicine residency directors responded. There was no uniformity in the definition of a fever. Ninety-nine percent of the pediatric and 82% of the emergency medicine residency directors teach that all febrile infants less than 4 weeks of age should be hospitalized (P less than 0.0001). Forty-six percent of residency directors teach that a lumbar puncture should be performed for all children less than 12 months of age with their first febrile convulsion. Thirty percent of pediatric and 62% of emergency medicine residency directors teach that a blood culture should be obtained from a child with fever without source who is younger than 24 months of age (P less than 0.0005). Nonspecific tests are taught to be used to determine which febrile child should have a blood culture as follows: white blood cell count, 50%; differential, 20%; erythrocyte sedimentation rate, 13%; and C-reactive protein, 2%. There was little uniformity of teaching regarding the approach to the febrile child and there were significant differences in training by specialty.     

Leadership Training in Pediatric Residency Programs: Identifying Content,Characterizing Practice,and Planning for the Future

ObjectivePhysicians serve as leaders in varying roles, but often with minimal dedicated training. Existing pediatric residency competencies may not completely describe all leadership skills that should be valued. We sought to identify a set of high-value leadership skills and evaluate current training in these skills in pediatric residency programs.MethodsA modified Delphi process was used to inform a national survey of pediatric residency program directors. Programs were asked to rate the perceived importance of identified leadership skills and the presence of dedicated teaching. Skills identified as extremely or quite important by ≥90% of respondents were classified as high-value.ResultsOur modified Delphi process generated 16 core leadership skills to evaluate. A total of 67/204 residency programs responded. Six skills were identified as high-value: managing time effectively, receiving feedback, communicating effectively through speaking, embodying professionalism, demonstrating emotional intelligence, and addressing conflict. Only 19% of responding programs reported providing dedicated teaching time for all high-value skills.ConclusionsDespite a high degree of national agreement among program directors about the importance of specific leadership skills, few pediatric residency programs dedicate time to teaching residents about these skills. The identified high-value leadership skills could help to inform future educational efforts.     

Pediatric Emergency Medicine Fellowship survey: 1991-1992.

This study was designed to determine the general characteristics, training expectations, and career goals of those individuals entering Pediatric Emergency Medicine Fellowships in 1992 through the NRMP Pediatric Emergency Medicine Match. A 20-item questionnaire was developed and sent to those individuals who successfully obtained fellowship positions through the 1991-1992 Match. All of the respondents will have completed a formal pediatric residency program, and 90% will have completed their residency since 1990. Eighty-eight percent of the respondents have not completed formal postgraduate training other than a pediatric residency, and none of the respondents were from training programs in emergency medicine. Ninety percent of the respondents are planning on two years of training, while 10% are either entering a three-year program or planning an optional third year. Ninety-four percent of the individuals who responded had not applied for Pediatric Emergency Medicine Fellowships in the past, but, while many of the individuals were concerned about obtaining a position, only 6% applied for a fellowship in an alternative field. If the respondents had not obtained positions this year, 79% felt that they would have reapplied next year. When asked why they are pursuing a Pediatric Emergency Medicine Fellowship, 85% listed opportunities in clinical medicine as their primary reason, while 10% claimed that research opportunity was the most important factor. When their fellowships are completed, 77% hope to practice at a university-based children's hospital, and 10% hope to practice at a private children's hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quality of training and professional outcomes of medical students in pediatric residency programs: survey of graduating classes between 1990 and 2000, in the western interregion]

OBJECTIVES: Little information is available to incoming students in pediatrics residency programs on the experiences of past residents. The objective of this study was to investigate the pediatrics training programs and determine the professional outcomes of graduating residents between 1990 and 2000 in the Western Interregion. POPULATION AND METHODS: Questionnaires were distributed to the 187 medical students enrolled in pediatrics residency programs between 1990 and 2000 in the six university hospital centers of the Western Interregion. The questions concerned the details of training, the modes of residency positions, and current professional and personal situations. One hundred and sixty-five (88%) individuals responded. RESULTS: Seventy-seven percent of the practicing pediatricians stated that the training they had received during residency was adapted to their current practice. This percentage was higher for hospital staff physicians (82%) than for the physicians in private practice (50%) or those with salaried positions outside the hospital system (58%). One hundred and twenty-four had either completed post-residency training (97) or were doing so (27) at the time of the survey. All but one were professionally active, three quarters of them in hospitals and, of these, most were in the hospitals where they had trained. Eighty-six percent of the practicing pediatricians said they were satisfied with their professional work and 73% said they were satisfied with their personal lives. CONCLUSION: These results support the current reflection on reforming the residency training program in pediatrics, especially with regard to its prolongation and the diversification of the training options to take into account the individual student's professional orientation.