The Continuum of Pediatric Medical Education and Life-Long Learning
Article Outline
- Medical School Applicant Selection
- Medical School Education
- Post-Graduate Education
- Practice of Medicine
- Discussion
- References
- Copyright
The Accreditation Council for Graduate Medical Education has outlined competencies for residents to attain, and the Milestones Project1 has helped delineate more specific goals for pediatrician development. Our medical schools and the American Board of Medical Specialties have also modified competencies applicable to corresponding stages of professional development. However, our curricula are bursting at the seams, and demands for attention to non-traditional competencies are increasing. How can educators ensure adequate skills, attitudes, and knowledge and prepare future physicians for practice in a system that is in transition politically, socially, and technologically? In view of all the changes taking place in medical education and clinical care, it is time to revisit the basic components of a thorough and competent pediatric education.
Beginning with the end in mind, a good physician should possess a solid fund of knowledge, good decision-making skills, emotional steadiness, a collaborative approach to clinical care with the ability to function as both a member and a leader of a team, and compassion and empathy. A physician needs to be resilient, flexible, and a life-long learner, because healthcare continually changes—no small feat for only 7 years of medical education! Furthermore, Hackbarth and Boccuti state that to improve health care value ultimately, physicians must possess new perspectives and skills for evidence-based practice, effective use of information technology, quality measurement and improvement, cost awareness, care coordination, leadership of interdisciplinary teams, and shared decision-making.2 They posit that the first step toward a more effective and sustainable healthcare system is to match the content of training to these needs. Adding more to the curriculum is not practical; therefore, cultivating self-directed learning, reflection, and self-assessment during training and in practice is essential to achieve the non-traditional competencies aforementioned.
Medical School Applicant Selection
Before we begin to educate, we first must meet the challenge of selecting students who are likely to succeed. The continuum of medical education actually begins with the undergraduate degree, which traditionally has been science based. An undergraduate science background may produce high Medical College Admissions Test scores, but may not contribute to the development of other skills. The Medical College Admissions Test itself has been revised with the addition of the written essay section to provide broader information about applicants. In his essay from more than 30 years ago, Lewis Thomas discusses premedical education and focuses on the importance of a liberal education. He suggests that we encourage college students to veer away from an overly specialized education and encourage them to develop as fully as possible as human beings before entering medical training.3 More recent studies demonstrate that skills such as the ability to use technology, being honest and truthful, exploring self-education and research, and the ability to communicate orally are essential skills of successful students and practitioners of medicine.4 The use of structured interviews and multiple mini-interviews are modalities that may enhance the selection of students with non-cognitive skills compatible with the expectations of a competent physician.5 By moving away from the “science-focused” college preparation, we may be more effective at bringing well-rounded individuals with a foundation of resilience, self-awareness, and solid, self-directed learning skills and cultural sensitivity in the pipeline of future physicians.
Medical School Education
Once accepted, the student enters the medical education curriculum. The goal of basic science education is to provide students with a broad, solid foundation. Students need a thorough understanding of the scientific method and the ability to transfer new knowledge thoughtfully and carefully to patient care to practice evidence-based medicine. By introducing clinical experiences earlier in the curriculum, medical schools are fostering the integration of these bodies of knowledge. Lambert et al conclude that personalizing science education after the acquisition of requisite standardized knowledge encourages students to consider their own educational needs in relationship to their career aspirations.6 The shift from predominantly requisite knowledge acquisition to the personalization of knowledge acquisition continues into graduate medical education and medical practice (ie, the development of life-long learning skills).
“Learner-centered education” is the term used by Curry and Montgomery to describe the flexibility incorporated into undergraduate medical education that may nurture intellectual curiosity in students.7 This is not intended to supplant core knowledge, skills, and attitudes and should not simply be “tracks” toward early specialization. Instead, this approach gives students the opportunity to gain perspectives and expand skills before entering their specialty. This could include courses on leadership, work on a quality improvement project, a “capstone”/residency readiness elective, research, or patient advocacy. Focusing on personal and professional goals enhances student learning and perhaps increases what they bring to the next stage of professional training. This approach was used in the collaborative efforts of the Association of Pediatric Program Directors and the Council on Medical Student Education in Pediatrics to produce the Pediatrics Subinternship Curriculum. One recommended activity is for students to identify learning plans to discuss with faculty at the beginning and end of the rotation. Ultimately, when orchestrated well, this activity facilitates and stimulates reflection, self-directed learning, and self-assessment, bridging the transition to residency training.
Post-Graduate Education
Once a student enters a residency program, training commences with very specific rotation requirements and curricula, with increasing opportunity for personalized “elective” experiences in the second and third years. The Pediatric Residency Review Committee guidelines mandate that residents reflect on their strengths and limitations and complete individualized learning plans. The Pediatric Residency Review Committee emphasizes that it is critical that self-reflection and lifelong learning permeate the entire training process to ensure that trainees are prepared for independent professional practice. Is it working? Li et al published data obtained from more than 900 pediatric and internal medicine/pediatric residents about their strategies for achieving learning goals and barriers that they face.8 Survey results identified several barriers to achieving learning goals. The barriers were categorized as difficulty with personal reflection, environmental strain, competing demands, difficulty with goal generation, and problems with plan development and implementation. Even at the postgraduate level, guidance is needed to assist residents in overcoming barriers to learning plan generation.
Practice of Medicine
Medical school and residency lay the groundwork for professional practice. A formal transition to full practice does not typically occur outside of the orientation and mentoring that is done by other members of a group practice. Ongoing formal and self-directed education is necessary to achieve practice goals and attain and maintain board certification. According to the American Board of Medical Specialities, specialty certification “signals” a physician’s commitment and expertise in consistently achieving superior clinical outcomes in a responsive, patient-focused setting. Key processes in maintenance of certification include life-long learning and self-assessment and practice performance assessment, which constitutes most of the process beyond the cognitive examination. The planning and implementation of continual learning rests on the physician.
Discussion
The education of a pediatrician involves enormous planning and effort. Crucial to the future success of the pediatrician is a well-developed ability to reflect and direct further learning, because of the increasing volume of knowledge and skills expected of a practicing physician. Recommendations to support this process include focusing on non-cognitive skills, in addition to cognitive qualities, of applicants to medical schools. During medical school, student curiosity should be encouraged and supported by the ability to choose and design experiences (with appropriate faculty guidance) after a core set of knowledge and skills is accomplished. This guidance should continue through residency and even perhaps be available to the practicing physician. The educational community should collaborate and focus on transitions between levels of training, including entrance in the practice workforce. Finally, increased research focused on outcomes, rather than processes, is important. We need to know that our efforts truly impact patient outcomes and are valuable to practicing physicians as well.
References
- The pediatrics milestones: conceptual framework, guiding principles, and approach to development. J Graduate Med Education. 2010;2:410–418
- . Transforming graduation medical education to improve health care value. N Engl J Med. 2011;364:693–695Epub Feb 9, 2011
- . Notes of a biology-watcher. How to fix the premedical curriculum. N Engl J Med. 1978;298:1180–1181
- . Creating anew paradigm for premedical undergraduate studies: physicians’ perceptions of subjects and skills critical for success in medical school and practice. Med Education Online. 2006;11:24
- . The ability of the multiple mini-interview to predict preclerkship performance in medical school. Acad Med. 2004;79:S40–S42
- . Standardizing and personalizing science in medical education. Acad Med. 2010;85:356–362
- . Toward a liberal education in medicine. Acad Med. 2010;85:283–287
- . Successful self-directed lifelong learning in medicine: a conceptual model derived from qualitative analysis of a national survey of pediatric residents. Acad Med. 2010;85:1229–1236
PII: S0022-3476(11)00386-6
doi:10.1016/j.jpeds.2011.04.017
© 2011 Mosby, Inc. All rights reserved.
