Value of a community pediatrics rotation for residents

Article Outline

• How is community pediatrics structured?
• How does the curriculum involve the community?
• How has the curriculum benefited our residents
• Future directions for community pediatrics
• References
• Copyright

Children are exposed to complex environmental and social circumstances which may adversely affect their health and wellbeing. If future pediatricians are to be responsive to these conditions and their likely effects, they need the knowledge and skills to reduce risks that exist within disadvantaged communities.¹ They must learn to identify and address undesirable conditions and work collaboratively with community partners to advance children’s health and wellbeing. Residents can be taught to influence outcomes for children at a community level and residency programs should expose them to community resources that complement their medical knowledge with others’ expertise. Community health improvement for children and families requires collaboration among child health professionals and advocates.²

Historically, residents spent the majority of their time being educated in hospital and clinic settings providing limited experience to recognize and address community concerns facing children. To train residents to recognize the complexities of children’s lives and learn how to become life-long advocates for families, the department of pediatrics at the Medical College of Wisconsin (MCW) and Children’s Hospital of Wisconsin (CHW) established a community pediatrics program. The Community Pediatrics Training Initiative (CPTI) initially supported by a grant from the Dyson Foundation of Millbrook, New York, under the direction of Anne E. Dyson, MD, funded 12 pediatric residency programs nationally, ranging in size from small programs such as the Naval Medical Center and the University of Hawaii which have 22 and 21 residents, respectively, to larger programs such as Indiana University (71) and Children’s Hospital of Philadelphia (111). Our CPTI with 60 residents was designed with four educational objectives: assessment and awareness of the social determinants of health; provision of culturally-sensitive, family-centered and community-based care that utilizes the assets of the community; implementation of surveillance to identify emerging health threats for children; and advocacy for children across all sectors and geographic levels. These objectives will be referenced in the description of our program.

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How is community pediatrics structured? 

Since 2000, all pediatric residents at MCW/CHW participated in community pediatrics. During the first postgraduate year, monthly conferences to discuss health-related and community-focused topics provide a foundation for subsequent years of community pediatrics training. During their second year, residents participate in a one-month rotation that covers topics described in Table I (available at www.jpeds.com). During the last postgraduate year, residents participate in quarterly sessions to revisit relevant child health topics.

Table 1. Sample of community pediatrics curriculum

The infrastructure for community pediatrics involves multiple stakeholders: interdisciplinary professionals and parents from community-based organizations, faculty, staff and residents. Community-based organizations (CBOs) are typically associated with the settlement house model.³ Low-income parents and interdisciplinary professionals actively engage in resident training as CBO representatives. These partners have a broad base of expertise including education, social welfare, and community organizing.

Faculty and staff from the department of pediatrics at MCW/CHW complement the community experiences of residents by interjecting into the discussions relevant programmatic and community activities to exemplify successes and shortcomings of theoretical concepts that guide service programs. For example, residents gain knowledge about the WIC program by partnering with a parent who is actively going through the certification process on site. In an attempt to understand the circumstances that lead to teens leaving their homes, residents interview a teen in a runaway shelter to discover how professionals might support teens in similar circumstances. Residents are encouraged to examine the roles that pediatricians can assume when it comes to schools, childcare, child welfare, food/economic security, public policy, etc. In addition, residents are challenged to explore the efficacy and effectiveness of these programs.

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How does the curriculum involve the community? 

Over 25 CBOs discussed their institutional objectives and accomplishments with residents. CBOs illustrate how they utilize community assets while following culturally-sensitive, family-centered and community-based approaches. Interdisciplinary professionals from the CBOs shared with residents how their disciplines approach community level issues. For example, a team of residents worked with a Head Start nurse to design an interactive curriculum to focus on healthy eating habits and physical activity for several children with obesity. An environmental youth counselor at a neighborhood center with overweight teenagers taught them how to plant vegetables and created a communal garden as an after-school activity.

From partnering CBOs, 45 parents have been trained to interface with residents, to identify areas of system barriers as well as to describe how families overcome obstacles. Parents participated in a 5-hour workshop that emphasized the topics shown in Table II (available at www.jpeds.com).

Table 2. Parent workshop topics

To enhance residents’ awareness of the social determinants of health, referred parents are willing to share “real life” experiences with pediatric residents and to expand their understanding of “what life is really like” for children with economic insecurities. Typically, participants share daily challenges as a single-parent, with limited health coverage, working at minimum wage, and living in lead-bated residential property. Parents participated in an average of nine sessions per rotation (range, 1-18).

To address the objective of identifying emerging health threats and advocacy for children, residents produced a series of practical community initiatives with themes ranging from improving access to health care, child advocacy and health education/promotion. An example of improving access to health care, residents surveyed 63 CBO parents about their need of daycare services for mildly-ill children. Of 63 parents surveyed, over 60% had problems finding alternative daycare for sick children and had missed more than one week of work and/or school secondary to their children being ill. Residents concluded that these parents could benefit from daycare services and recommended a daycare model for mildly ill children. Another group of residents investigated the prevalence of cavities in toddlers and joined a coalition to advocate for Medicaid reimbursement to primary healthcare providers for fluoride varnish application. They also proposed that an educational program be developed to train residents how to perform oral health risk assessments and fluoride varnishes. Subsequently, a grant was acquired from the American Academy of Pediatrics to train community pediatricians and residents in preventative oral health. To address health education and promotion, residents designed a three phase community initiative in a predominantly Latino organization. While one group of residents developed a survey tool to identify health concerns of children 8-12 years of age, the next group used those questions in focus groups and the latter group implemented a health education curriculum, building upon the health concerns reported by children. All of these initiatives were proposed by CBO representatives and were accomplished through team efforts with residents.

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How has the curriculum benefited our residents 

A survey of 84 graduates (65% response rate) revealed that of the respondents, 100% reported that they are moderately to greatly prepared to collaborate and communicate effectively with their families and their responses are sensitive to patients’ culture, age, gender and disabilities issues, while 78% of respondents identified themselves as aware of delivery systems’ effects on quality and safety as well as prepared to act as a child advocate in their communities.

A self-assessment form of 28 likert-type questions was administered to residents before and after the rotation. Residents responded to each question about their perceived competence on a 5-point scale (1 = low and 5 = high). A factor analysis was conducted yielding five factors identified by expert community pediatricians. Data were collected and analyzed from forty residents between September 2003 - April 2005 and changes in competencies were compared using repeated measures analysis of variance. The following changes were reported before/after the rotation for each factor: advocacy (2.26 → 3.84); knowledge of poverty (2.45 → 3.92); professionalism and diversity (2.70 → 3.72); system-based practice (2.23 → 3.60), and team building (3.57 → 4.21). For all factors before and after the rotation, the mean ratings of residents increased and were highly significant to a p value less than 0.001.

In open-ended questionnaires, seventy-five percent of all residents (40) stated in their overall rotation evaluations that parental interactions were the most valuable experiences in providing clarity as to what children’s lives are like. Residents also stated that they learned about new community resources and appreciated the coping skills of families faced with resource challenges.

A national evaluation conducted by the Johns Hopkins University Bloomberg School of Public Health reported that CHW/MCW residents when compared to other residency programs without a similarly structured community pediatrics rotation, benefited by participating in community activities, spending time with peers and meeting residency requirements. In addition, they reported that community pediatrics had moderate to substantial influence on their future career activities.⁴

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Future directions for community pediatrics 

The transferability of knowledge and skills during this rotation needs to be examined within other disciplines of medicine such as internal medicine, family medicine, etc.. As we look for emerging health threats to families, it is evident that advocating for families could be enhanced with legal assistance made available for families needing housing, food, child care, health care, economic security, etc.⁵ To address this myriad of issues, residency programs need to continue to expand and develop evidence-based education through community-based participatory research. Future pediatricians’ board certification should incorporate competency measures being identified by community pediatrics programs throughout the nation.

References available at www.jpeds.com.

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References 

1. Dunnigan A , et al.   The essential role of research in community pediatrics . Pediatrics . 2005;115:1195–1201
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2. Shipley LJ , Stelzner SM , Zenni EA , et al.   Teaching community pediatrics to pediatric residents (strategic approaches and successful models for education in community health and child advocacy) . Pediatrics . 2005;115:1150–1155
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3. Smith RF . Settlements and Neighborhood Centers . In:  Edwards RL editors. Encyclopedia of social work . 19^th edition. Washington, DC: National association of social workers; 1995;p. 2129–2572
   • View In Article
4. Anne E. Dyson Community Pediatrics Training Initiative National Evaluation Johns Hopkins Bloomberg School of Public Health Women’s & Children’s Health Policy Center September 2004.
   • View In Article
5. Zuckerman B , Sandel M , Smith L , Lawton E . Why Pediatricians Need Lawyers to Keep Children Healthy . Pediatrics . 2004;114:224–228
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