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.     

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.     

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.     

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.     

Global health training in pediatric residency: a qualitative analysis of faculty director insights

ObjectiveInterest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.MethodsSeven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.ResultsAll programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.ConclusionsDirectors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.     

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.     

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.     

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.     

National survey of pediatricians' violence prevention counseling.

BACKGROUND: Recommendations for child health care providers to counsel patients and their families on violence prevention have been issued by a number of major health care organizations. OBJECTIVE: To assess the knowledge, attitudes, training, and practices of pediatricians concerning violence prevention counseling in the areas of family violence, discipline, television viewing, peer violence, and guns in the home. DESIGN: Survey. PARTICIPANTS: A national random sample of 1350 pediatricians, divided equally among residents in their final year of training, practitioners who had completed their residency training within the last 5 years, and those who had completed their training more than 5 years ago. MAIN OUTCOME MEASURES: Knowledge, attitudes, training, and current practices regarding violence prevention counseling. RESULTS: The overall response rate was 41%. When providing health supervision to patients, most pediatricians never or rarely screen for family and community violence, peer violence, and weapons. For example, 68% of residents and 73% of practitioners never or rarely screen for domestic violence, 56% of residents and 67% of practitioners never or rarely ask adolescents about their involvement in physical fighting, and 54% of residents and 56% of practitioners never or rarely identify families who have guns in the home. Regarding preparation for providing violence prevention counseling, 76% of residents and 83% of practitioners rated their training as inadequate. Receiving training in the prevention of child/adolescent violence in medical school (P<.001), residency (P<.001), or fellowship/continuing medical education (P=.002) were major determinants of more frequent violence prevention counseling. Pediatricians who believed that parents rarely or never follow through on a physician's advice about safe gun storage, switching to nonviolent disciplining techniques, or limiting their child's television viewing were less likely to ask or advise patients in these areas. CONCLUSIONS: Pediatricians are not adequately prepared to provide violence prevention counseling, and few currently screen for exposure to family and community violence, peer violence, and access to weapons. Comprehensive information about violence prevention should be integrated into medical education, and the efficacy of violence prevention counseling strategies should be evaluated.     

Pediatric residents' knowledge of the community

ObjectiveThe purpose of this study was to examine pediatric residents’ knowledge of the communities they serve through their continuity clinics.Design/MethodsThe community was identified for each of 6 continuity clinics at an urban children’s hospital by geocoding patient addresses using GIS software (1 hospital-based [n = 36], 1 primary care track site [n = 10], and 4 community clinics [n = 12]). We assessed resident and attending knowledge with a survey examining 7 content areas with basic questions about these communities. The survey answers were compared with publicly available community data.ResultsA total of 37 of 57 eligible residents (65%) and 21 of their 23 attendings (91%) completed the survey. The residents achieved an overall mean score of 28.9% correct (SD 9.2) and attendings scored 42.6% (SD 19.7). Scores were significantly greater for community-based attendings overall (P < .002) and for community-based residents only in the questions of schools (P < 0.001). However, community-based residents had poorer scores in the demographics/economics content area (P < 0.001). Scores were not correlated with year of residency.ConclusionsOur pediatric professional organizations have recognized the importance of training residents in community pediatrics. This study is the first to describe resident community knowledge and to demonstrate that this knowledge is generally poor, with specific gaps in the content areas of schools, daycares, and health care access. There are differences in areas of knowledge between those working in hospital versus community clinics, suggesting this is an area for further investigation.     

Resident training in pediatric critical care transport medicine: a survey of pediatric residency programs

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) Program Requirement for Pediatrics includes specific objectives that pediatric residents participate in both the pre-hospital care of acutely ill or injured patients and the stabilization and transport of patients to critical care areas. Previously, residents were often included as the physician component for many pediatric critical care transport teams. Subsequent regionalization of transport services and development of nurse-only transport teams prompted us to determine the current level of resident participation in pediatric critical care transport as well as how individual residency programs were meeting the educational objectives. METHODS: A questionnaire was mailed to each pediatric residency program listed in the 1996-1997 GME Directory. Information was obtained regarding the size of the hospital and the residency program, the presence of a pediatric critical care transport team, the number of annual transports, and transport team leader. In addition, the use of pediatric residents for transports was ascertained, as well as their specific role, training requirements, and method of evaluation. RESULTS: Data were received from 138 programs for a return rate of 65%. Eighty percent of programs offered a pediatric critical care transport service. Nurse-led teams were used for 51% of NICU and 44% of PICU transports. Of the 82 NICU and 84 PICU teams that used residents, the majority used them as team leaders (60% and 70%; respectively) with only the minority requiring that they be at the PL-3 year or greater. The training and/or certification required for resident participation in transports varied among programs, with 85% requiring completion of a NICU or PICU rotation, and 94% requiring NRP or PALS certification. Programs that did not allow resident participation provided exposure to Transport Medicine by various mechanisms, including lectures and emergency department (ED) rotations. CONCLUSION: Pediatric resident participation in critical care transport varies widely among pediatric critical care transport teams. The degree to which residents participate in the transport team would appear to have diminished in comparison to previous studies. Transport teams often use other resources, such as nurses, fellows, or attendings, to lead their transport teams. Pediatric resident exposure to and participation in Transport Medicine varies among programs, as do the methods used to prepare residents for their experience.     

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.     

School health training during pediatric residency

Pediatricians are becoming increasingly concerned about reaching beyond the office or clinic to help solve problems of child and family health. The physician's ability to interact with school personnel and communities is one important approach to this outreach effort. School health training has been a required 6-month component of the pediatric residency curriculum at the University of Texas Medical Branch, Galveston, since 1979, with second-year residents providing weekly on-site consultations to public school districts and participating in a weekly school health seminar series. In this study, graduates from this program were surveyed to determine their evaluations of the training and extent of current school involvement and to use their evaluations for curriculum evaluation. Residents who participated in the school consultation from 1979 through 1988 were surveyed. Seventy-eight pediatricians responded, a 79% return rate. Ratings by the graduates reveal that both pediatric generalists and subspecialists highly value their training experiences. Ratings were not related to the specific site to which the resident consultant had been assigned. Of these pediatricians, 41% are currently consulting with school personnel. These findings are discussed as they relate to other reports of physician involvement in schools and provide clues to curriculum design for school health training in pediatric residency.     

A Proposed Model Curriculum in Global Child Health for Pediatric Residents

ObjectiveIn response to the increasing engagement in global health (GH) among pediatric residents and faculty, academic GH training opportunities are growing rapidly in scale and number. However, consensus to guide residency programs regarding best practice guidelines or model curricula has not been established. We aimed to highlight critical components of well-established GH tracks and develop a model curriculum in GH for pediatric residency programs.MethodsWe identified 43 existing formal GH curricula offered by U.S. pediatric residency programs in April 2011 and selected 8 programs with GH tracks on the basis of our inclusion criteria. A working group composed of the directors of these GH tracks, medical educators, and trainees and faculty with GH experience collaborated to develop a consensus model curriculum, which included GH core topics, learning modalities, and approaches to evaluation within the framework of the competencies for residency education outlined by the Accreditation Council for Graduate Medical Education.ResultsCommon curricular components among the identified GH tracks included didactics in various topics of global child health, domestic and international field experiences, completion of a scholarly project, and mentorship. The proposed model curriculum identifies strengths of established pediatric GH tracks and uses competency-based learning objectives.ConclusionsThis proposed pediatric GH curriculum based on lessons learned by directors of established GH residency tracks will support residency programs in creating and sustaining successful programs in GH education. The curriculum can be adapted to fit the needs of various programs, depending on their resources and focus areas. Evaluation outcomes need to be standardized so that the impact of this curriculum can be effectively measured.     

Pediatric radiologist-driven didactics for a pediatric residency program: a quality initiative

Background

Pediatric residents exhibit knowledge gaps in appropriateness of imaging utilization.

Objective

This study evaluates the value of radiologist-driven imaging education in a pediatric residency program. The primary goals of this educational program were to provide pediatric residents with resources such as the American College of Radiology Appropriateness Criteria, support optimal resource utilization and patient care, increase resident understanding of radiation risk, and determine the value of integrating radiologists into pediatric education.

Materials and methods

A needs assessment was performed in which the chief residents of a large pediatric program were surveyed. The consensus of chief residents was that a four-part lecture series delivered by a pediatric radiology fellow would be beneficial to the pediatric residents. Topics included general radiation risk as well as basic imaging topics in the chest, abdomen, neurological system, extremities and vasculature. Each lecture integrated appropriate ordering, ALARA (As Low As Reasonably Achievable)/Image Gently, and basic image interpretation. Residents were asked, using a Likert scale, to rate their understanding of radiation risk, the ACR Appropriateness Criteria, and other topics of interest before and after each lecture. Pediatric residents were given a 10-item quiz before and after the lecture series to assess their knowledge regarding the best test to order in clinical scenarios.

Results

The average pre-lecture score for knowledge of radiation risk was 3.27 (95% confidence interval [CI]: 3.02–3.51) out of 5, which improved to 4.27 (95% CI: 4.09–4.57) post-lecture. There was an increase in understanding of ACR appropriateness, with pre-lecture rating of knowledge increasing from 1.91 (95% CI 1.54–2.29) out of 5 to 3.61 (95% CI 3.33–3.90) post-lecture. The residents averaged 82.7% (95% CI 77.3%–88.1%) on the appropriateness pre-test and 93.8% (95% CI 90.3%–97.2%) on the post-test. Residents provided positive feedback upon conclusion of the program and reported a beneficial effect on their education.

Conclusion

A radiologist-driven lecture series in a pediatric residency can improve resident understanding of appropriate ordering practices and radiation risk. Radiologist participation in pediatric residency training is well-received.

     

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.     

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.