The Journal of Pediatrics
Volume 154, Issue 2 , Pages 157-158.e3, February 2009

The Future of Pediatric Residency Education: Prescription for More Flexibility

  • M. Douglas Jones Jr, MD

      Affiliations

    • Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
    • Corresponding Author InformationReprint requests: M. Douglas Jones, Jr, MD, Department of Pediatrics, Section of Neonatology, University of Colorado Denver School of Medicine, Mail Stop 8402, Education 2 South, Room 4304, 13121 E 17th Avenue, PO Box 6508, Aurora, CO 80045
    • ,
  • Gail A. McGuinness, MD

      Affiliations

    • American Board of Pediatrics, Chapel Hill, NC
    • ,
  • Residency Review and Redesign in Pediatrics (R3P) Committee

      Affiliations

    • A list of R3P Committee members is available at www.jpeds.com (Appendix 1). The R3P Project was funded by the American Board of Pediatrics Foundation with the support of the American Board of Pediatrics. The authors declare no conflicts of interest.

Article Outline

 

No physician forgets what it was like to be a resident. The anxiety and exhilaration that comes with new situations and challenging patients are not unique, but residency combines them with special salience. Stories, mentors, colleagues, children, and parents come to mind again and again. This is only one reason why opinions about what residency was, is, and should be are seldom dispassionate.

It was therefore with trepidation that the Residency Review and Redesign in Pediatrics Project (R3P) Project embarked on a comprehensive evaluation of pediatric residency education. The first such project was conducted more than 30 years ago.1 Broad concepts pertaining to residency education were reevaluated and updated by the Future of Pediatric Education II Project in 2000.2 Detailed requirements that residency programs must meet for accreditation are reviewed every 5 years by the Review Committee (RC) for Pediatrics of the Accreditation Council for Graduate Medical Education (ACGME) and incorporated into the ACGME's Program Requirements for Pediatric Residency Education.3 The R3P Project, led by a broadly representative R3P Committee, reconsidered all of this in the broadest possible context of what is likely to evolve over the next 15 to 20 years. Participants emerged chastened by the complexity of the undertaking but confident that pediatric residency education can adapt to the future while retaining important elements of the past and present. The 3-year process4 had but one purpose: to improve the health of children.

To accomplish its task, the R3P Committee drew on the expertise of its membership, a larger Project Group, invited topic experts, skilled facilitators,5 and the pediatric and health care community at large.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 It also surveyed residents, subspecialty fellows, and generalist and subspecialty practitioners for their views regarding the strengths and weaknesses of residency education.18, 19, 20, 21, 22 The Committee declined to make recommendations for one-time, immediate change; instead, it advocated a process of ongoing, evidence-based change.23

The R3P Project produced 3 major products: a list of themes that will be of future importance to pediatricians, a prioritized list of goals for innovative change based on these themes, and a process through which sustained adaptive change can occur.23, 24 Project reassessed fundamental assumptions on which current approaches to residency education are based.

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Themes 

The Project devoted considerable time to imagining what the next 15 to 20 years might bring.24 While precise predictions are impossible, participants reached consensus on 3 broad categories of themes for the future (additional information in Appendix 2; available at www.jpeds.com):

1.Pediatric careers, even within general pediatrics, are increasingly diverse,18 and the knowledge and skills needed for those careers are increasingly differentiated. General pediatric residency education must become both more flexible and more focused. It must be sufficiently flexible to allow residents to focus their education on their career choices. This parallels the conclusions of educators in internal medicine12, 13, 14, 15 and family medicine16 and of the Council on Graduate Medical Education.25 If general pediatricians who practice ambulatory or a combination of ambulatory and hospital pediatrics are to continue to be experts in providing comprehensive care for children and adolescents with chronic physical, mental, developmental, and behavioral disorders, residency education must ensure that they emerge with a solid foundation. A general pediatrician intending to practice hospital-based pediatrics needs an equally solid, but different, foundation. The underlying principle, which remains difficult for some to acknowledge,26 is that competence is context-specific;27, 28 knowledge and skills that fit one setting do not automatically transfer to another setting. This also is important when considering how to facilitate later changes to the focus of practice and practice reentry after prolonged absence.28

2.Society and pediatric health care are changing. More flexible pediatric residency education is best able to prepare residents for societal and health care trends that will evolve in unpredictable, interactive ways. Chronic, rather than acute, conditions are now the chief causes of health-related morbidity and mortality in children, adolescents, and young adults.6, 7, 8 This means that health care is increasingly the product of teams of professionals and parents, rather than individual physicians.6, 7, 8 Changing family structures are important determinants of access to care.29 The cultural diversity of children, parents, and the pediatric workforce is increasing.30 Biomedical and psychosocial knowledge continue to grow. Information technologies used to access knowledge and exchange information are growing as well, in ways that are changing the relationship of practitioners to patients and families31 and to one another. Finally, professional expectations of the pediatric workforce are changing, with increasing emphasis on family and personal priorities.19, 32

3.Concepts and process of medical education are changing. Education outcomes are increasingly important.33 This enables changes in process, provided that outcomes are documented. Greater emphasis on health outcomes has led to greater appreciation of the need to integrate learning and maintenance of competency from medical school to resident education to continued, career-long professional development.34 Regardless of the specifics of an education program, the knowledge and skills needed for quality improvement and self-directed life-long learning, energized by a strong sense of professional and personal responsibility, are paramount and must be taught as such and by example. Pediatric residents are closely supervised, and opportunities for independent decision-making are inevitably limited. The transition from residency to workplace may be difficult, especially for residents headed for general ambulatory pediatric practice. More information is needed on learning during that time.35 Finally, the advice and counsel of patients and parents must be considered when designing education programs for pediatricians.

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Goals 

The R3P Committee endorsed 3 specific goals for transformative change in pediatric residency education (additional information in Appendix 3; available at www.jpeds.com):

1.Pediatricians should be prepared for diverse careers in the care of children, adolescents, and young adults. In addition to providing a foundation in general pediatrics, pediatric residency education should offer programs that prepare residents for the diverse and emerging healthcare needs of children.

2.Pediatric education must provide a continuum of learning that begins in medical school. Residency programs should develop innovative mechanisms for tying residency to medical school and postresidency learning.34

3.Pediatricians must close the gap between current and optimal health care outcomes for children, adolescents, and young adults. Excellent residency education requires an environment of excellent clinical care, so that residents learn to adhere to acknowledged care guidelines36 as they constantly evaluate and improve their practice.

The Committee suggested that programs look to other issues that are important both in and of themselves and as methodologies for achieving transformative change. In particular, the participants hope that programs will explore ways to reduce fragmentation of education experiences.37 Perhaps some programs will experiment with partial elimination of block rotations and/or integrated educational opportunities tailored to particular careers. Other items merit attention as well. Programs should test ways of providing for self-assessment and external assessment to help residents internalize a sense of personal responsibility for learning and patient care. Explicit preparation for life-long learning also has been suggested by internal medicine educators.12 Programs should explore means by which residents can function as credible members of healthcare teams, which is unlikely if residents participate only during single block rotations. Programs need to explore approaches that foster residents' self-confidence by balancing experiences in which residents are members of teams caring for complex patients with experiences in which residents are on their own, confronting novel situations and caring for less complex patients. Identifying the best ways to assess residents' accomplishment in the 6 ACGME competencies3, 38 should be accompanied by exploration of ways to provide for the professional development of teaching faculty. The impact of using residents for clerical tasks that are better done by others should be investigated. Finally, programs need to determine the value of incorporating simulation and computer-based learning into residency education.39

The Committee came to question 2 fundamental assumptions underlying generalist education: (1) that one residency curriculum suffices for all general pediatric residents (this was discussed earlier and is being challenged by others)40; and (2) that each resident should be exposed to the greatest possible breadth of pediatric knowledge and clinical experience. The scope of pediatric practice has long since passed the point at which a truly comprehensive resident experience is possible unless a substantial portion of it is superficial. Another year of training would provide only temporary relief. The deliberate practice essential to the acquisition and enhancement of competence41 cannot occur unless depth takes precedence over breadth. If all experiences are implicitly equally valuable, then prioritizing education goals to match career choices becomes impossible; the R3P Project concluded that goals and objectives of general pediatric residency education should be tailored to the specific epidemiology of conditions that residents are most likely to encounter in later practice. This may be viewed as patient-centered education best suited for later patient-centered care.

The R3P Project has developed a challenging strategic plan. As difficult as this has been, the real work lies in implementation. Representatives of the R3P Committee and the RC for Pediatrics have drafted a document to solicit innovative proposals for change from residency programs. Successful proposals will be eligible for waivers of RC requirements. Committee representatives are also working with the RC, the Association of Pediatric Program Directors, the AMSPDC, the Resident Section of the AAP, and the ABP to create an organization to oversee ongoing adaptive change in pediatric education. If done properly, the process of gathering persuasive evidence on which to base changes will inevitably be slow. We look forward to beginning in 2009.

References are available at www.jpeds.com.

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Appendix 1: R3P Committee Members 

R3P Committee 

Myles B. Abbott, MD

H. James Brown, MD

Carol L. Carraccio, MD

Lewis R. First, MD

Aaron L. Friedman, MD

Laurel K. Leslie, MD

George Lister, MD

Theresa C. Murdock-Vlautin, MD

Robert H. Perelman, MD

Theodore C. Sectish, MD

James A. Stockman III, MD

M. Douglas Jones, Jr, MD, Chair

Gail A. McGuinness, MD, Vice Chair

R3P Project Group 

Richard E. Behrman, MD

Carol A. Berkowitz, MD

Thomas F. Boat, MD

Laura M. Brooks, MD

Ann E. Burke, MD

Barbara B. Calkins, MD

Russell W. Chesney, MD

Mary R. Ciccarelli, MD

Gary L. Freed, MD

Elena Fuentes-Afflick, MD

J. Carlton Gartner, Jr, MD

Anita D. Glicken, MSW

Larry A. Green, MD

Thomas N. Hansen, MD

Eric S. Holmboe, MD

Kevin B. Johnson, MD

Amy E. Jost, MD

Jeffrey M. Kaczorowski, MD

Diane Kittredge, MD

J. Lindsey Lane, MD

David C. Leach, MD

Linda G. Lesky, MD

Sarah S. Long, MD

Stephen Ludwig, MD

Edward R.B. McCabe, MD

Julia A. McMillan, MD

Alan K. Percy, MD

Kenneth B. Roberts, MD

Norman M. Saba, MD

Jo Ann Serota, MSN, RN, CPNP

F. Bruder Stapleton, MD

Maren C. Stewart, JD, APR

Modena E. Wilson, MD

Barry S. Zuckerman, MD

R3P Project Advisors, Colloquia I-III 

Tina L. Cheng, MD

Paul V. Miles, MD

Edward L. Schor, MD

Paul H. Wise, MD

Topic Experts, Colloquium II 

Helena A. Davies, MBChB (Hons), MD, FRCPCH

Robert I. Hilliard, MD, EdD

Eric S. Holmboe, MD

Ann C. Jobe, MD, MSN

Paul V. Miles, MD

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Appendix 2: Themes of the future in pediatric health care 

Uncertainties about the future of pediatric health care, along with uncertainty regarding the public's ability and willingness to pay for that health care, argue for models of pediatric education that are sufficiently flexible to provide for a wide variety of professional futures. The R3P Project recognizes that a number of factors must be considered as part of a comprehensive evaluation of the current status of pediatric residency education and the necessary refinements for future pediatric residency education over the next 15 to 20 years. These include the following:

1.Changes in society and health care
a.A shift in the causes of health-related morbidity and mortality in children and adolescents from acute to chronic illnesses and disorders, as well as increased appreciation of the importance of the prenatal period and childhood to the occurrence of disease throughout the life course

b.Changes in families that may impede access to health care, especially more single-parent families and families in which both parents work

c.Increasing cultural diversity of children and parents, with a corresponding need for effective ways of increasing cultural competence and cultural diversity of the pediatric workforce

d.Changes in biomedical and psychosocial knowledge, as well as diagnostic and treatment methods

e.Changes in information technologies that affect access to health care information by health professionals, patients, and families, and the exchange of information among them

f.Changes in the expectations of the pediatric workforce, with more individuals seeking part-time employment and a generally greater emphasis on family and personal priorities.


2.The current and future practice of pediatrics
a.General pediatricians will continue to be the experts in offering a comprehensive approach to health care for children and adolescents, especially those with chronic physical, mental, developmental, and behavioral disorders. Pediatric education must ensure that distinct pediatric expertise in this regard continues to be maintained and enhanced.

b.The professional practices of pediatricians in large cities with ready access to subspecialists tend to differ from practices in smaller cities or rural locations. Roles also vary with the staffing structure of pediatric practices and local practice demographics. Pediatric education needs to acknowledge this diversity.

c.Pediatric health care is increasingly delivered by teams of professionals from health care and the community working in concert with patients and parents. Pediatric education must foster the development and maintenance of the leadership, collaboration, and communication skills needed to function within such teams.


3.Flexibility for multiple career paths and child health needs
a.Education in pediatrics must be flexible, acknowledging the diversity of pediatric practice and the variety of practice settings that exist now and will exist in the future. The current model of education must be compared with alternatives that allow for greater differentiation according to career goals.

b.Certification and maintenance of certification must be correspondingly flexible. Maintenance of certification must be able to accommodate reentry into practice after prolonged absences, as well as mid-career changes in the type of practice.


4.Changes in the educational process
a.No single educational method will suffice for pediatric education. The general principle, however, is that education must facilitate active personal ownership of learning; the process of training must foster reflective practice and develop the skills of self-directed life-long learning.

b.The expectations for pediatric education must be articulated and staged along the educational continuum, from medical school to resident education to continued, career-long professional development. Improving use of the fourth year of medical school to enhance pediatric education should be explored.

c.The “basic science” requirements for the study of pediatrics should be reexamined and possibly modified in terms of content and timing of learning.

d.Pediatric residents are closely supervised; opportunities for independent decision-making, even for advanced residents, are limited. The period of transition from residency to the workplace or to the next phase of training and education has become progressively important and should be critically analyzed.

e.The principles of continuous quality improvement must be taught as such and by example. Patient care and education must be both based on evidence where evidence exists and continuously reevaluated according to measured outcomes.

f.Pediatric health care is patient- and family-centered. The advice and counsel of patients and parents must be considered in the design of education programs for pediatricians.

g.Pediatricians must understand the principles of public health (ie, the health of populations as well as of individuals) to be effective care providers and advocates for children. This perspective must be incorporated across different stages of the educational process.

h.Evaluation of achievement of clinical competencies during residency requires appropriate mechanisms and competent evaluators. Programs to ensure competency in evaluation are urgently needed.


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Appendix 3: Goals for innovative change in pediatric resident education 

This appendix presents goals for transformative change. In all cases, residency education must emphasize the role of the pediatrician as child health advocate who has a view of the population of children and can work collaboratively with other disciplines to promote broad changes in child health. The goals are as follows:

1.Pediatricians should be prepared for diverse careers in the care of children, adolescents, and young adults. In addition to providing a foundation in general pediatrics, pediatric residency education should offer education programs that prepare residents for the diverse and emerging healthcare needs of children.

2.Pediatric education must provide a continuum of learning that begins in medical school. Pediatric residency programs should develop innovative mechanisms for tying residency to medical school and postresidency learning.

3.Pediatricians must be committed to closing the gap between current and optimal health care outcomes for children, adolescents, and young adults. Excellent residency education requires an environment of excellent clinical care so that residents learn to adhere to acknowledged care guidelines as they constantly evaluate and improve their practice.

Programs might choose to use 1 or more of the following strategies to assist in achieving transformative change:

•Improve child health outcomes and resident education by minimizing fragmentation of resident experiences and resident–faculty interactions. The negative effect of fragmentation of care and education, especially the effect on the development of a graduated sense of independent resident responsibility, must be addressed.

•Develop skills to internalize a sense of personal responsibility for learning and patient care beginning in medical school and continuing through residency and beyond. Pediatric residency programs should provide for self-assessment and external assessment supplemented by documentation that residents have internalized the sense of professional responsibility needed to maintain competence throughout a career.

•Prepare pediatricians to function as members of healthcare teams. Pediatric residency education should provide residents with opportunities to function as authentic members of healthcare teams.

•Develop skills in critical thinking, decision-making, assessment of evidence, and prioritization in evaluation and management of children, adolescents, and young adults with unusual presentations of common health problems or with disorders of unknown origin. Pediatric residency education needs to ensure a balance between experiences in which residents are members of teams caring for complex patients and experiences in which residents gain confidence when caring for less complex patients and confronting novel situations.

•Assess the 6 ACGME competencies using valid and reliable measures. Pediatric residency education should document accomplishment in each of the 6 competencies, as well as the effect on patient outcomes.

•Prepare faculty to teach, assess, and counsel residents. Pediatric residency programs should provide for faculty development in education and provide teaching faulty with adequate time, resources, and professional rewards.

•Organize the medical education workplace for maximum efficiency and health outcomes. Pediatric residency programs should improve health outcomes by eliminating the use of residents to perform administrative and clerical tasks better done by others.

•Explore innovative methodologies for improving education and patient outcomes. Pediatric residency programs should integrate new evidence-based approaches to teaching, learning, and assessment, such as simulation and computer-based technology, to improve both patient care and education.

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References 

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PII: S0022-3476(08)00953-0

doi:10.1016/j.jpeds.2008.10.040

Refers to erratum:

  • Correction

    The Journal of Pediatrics April 2009 (Vol. 154, Issue 4, Page 629)

The Journal of Pediatrics
Volume 154, Issue 2 , Pages 157-158.e3, February 2009

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