Pediatric Residencies: Differences Between 1959/1960 and 1984/1985

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Pediatric

Residencies:

Differences

Between

1959/1960

and

1984/1985

Christine

R. Bryke,

MD, Walter

W. Tunnessen,

Jr, MD,

Thomas

J. Scully,

MD, and

Frank

A. Oski,

MD

From the Department of Pediatrics, State University of New York, Health Science Center at Syracuse

ABSTRACT. Patient contact data, collected by two

first-year pediatric residents, separated in time by 25 years,

were compared, and it is concluded that pediatric

resi-dency has undergone major changes throughout the past

quarter century. Pediatric training has increased in

length and includes more female residents. The overall intensity of patient care pediatric residents provide has increased. Children with chronic disorders that were

often lethal conditions 25 years ago now make up a large portion of pediatric admissions to teaching hospitals. Pediatrics 1988;82:752-755; pediatric residency training, pediatric internship.

Most pediatricians agree that pediatric residency has changed during the past 25 years but, to our

knowledge, there are no reports documenting this

in the literature. We were able to find few

publica-tions describing the experiences of first-year

pedi-atnic residents’3 and none contrasting those

expe-niences with those of first-year residents who

trained a quarter of a century ago. An opportunity

to compare first-year programs was made possible

through information collected but not published by

T.S. in 1959 to 1960 and similar data prospectively

gathered by C.B. in 1984 to 1985. Review of their

data shows that pediatric residency training has

undergone a number of interesting changes over the past quarter century.

Descriptions of Residencies (Table 1)

Following his rotating internship, T.S. was a

first-year pediatric resident in 1959 to 1960 at the

Hospital of the University of Pennsylvania, (HUP).

Received for publication Aug 3, 1987; accepted Feb 25, 1988. Reprint requests to (C.R.B.) Yale University School of Medicine,

Department of Human Genetics, 333 Cedar St, P0 Box 3333, New Haven, CT 06510.

HUP was a primary care and referral center in

Philadelphia with 32 pediatric beds, a separate

sur-gical ward of 20 beds for which the pediatric

resi-dent served as medical consultant, a newborn

nuns-ery, and an outpatient clinic. His residency was 2

years in length. C.B. did her pediatric internship in 1984 to 1985 at the State University of New York,

Health Science Center at Syracuse. The latter

pro-gram is centered in two primary care and referral hospitals, one private and the other university based. State University Hospital (SUH) had 26 inpatient pediatric beds, a four-bed pediatric

inten-sive care unit, a separate pediatric emergency room,

and an outpatient clinic. Crouse Irving Memorial

Hospital, a private institution that is physically

joined to SUH, had a 30-bed inpatient pediatric

unit, a 38-bed neonatal intensive care unit, and 46

newborn bassinets. C.B.’s pediatric internship was

followed by 2 additional years of pediatric residency

training.

Although SUH and the HUP were both large,

general, full-service hospitals, they differed in their

population bases. SUH is the only university-based, tertiary care hospital in central New York. The

HUP, which has subsequently closed, was in a much

larger urban center with a number of other similar

hospitals, including two children’s hospitals.

Both physicians kept detailed records of all of

their patient care activities. Data collected regard-ing each medical patient included name, sex, race, diagnosis, attending physician, length of hospital stay, and follow-up. All patients admitted by and primarily treated by T.S. or C.B. were counted.

Patients for whom these residents assumed care

when they changed ward rotation were also

in-eluded. To be assured of its accuracy, C.B.’s patient

data was compared with that in the ward log books

before it was tabulated.

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7 5 4 4 3 2 2 2 2 2 2 ii 20 9 3 7 7 6 6 5 4 3 TABLE 1. House Officer Rotations*

ARTICLES 753

Rotation T.S.

1959-1960

C.B. 1984-1985

Wards 4 4

Clinic/emergency room 3 3

Nursery ₄ _3t

Growth and development 1

* Results are numbers of months. t Newborn intensive care unit.

ward duty, 4 months of outpatient and emergency room service, and 4 months in the nurseries. C.B.

was one of 11 pediatric interns, 45% of whom were men. Her rotations included 4 months ofward duty,

3 months of outpatient clinic and emergency room

experience, 3 months of neonatal intensive care

unit, and a 1-month rotation focused on normal

growth and development. Her ward duties, 2

months at each hospital, included daily pediatric intensive care unit rounds at SUH. Both residents were on duty for night call every third night.

The first-year pediatric residency training in

i959 to i960 and that in 1984 to 1985 were chosen for comparison because they are the beginning

years of pediatric training in the current and former

graduate medical education. We believe the

resi-dency experiences of T.S. and C.B. were similar to

those of other pediatric residents training at uni-versity-based hospitals during the same time pe-nods, but similar patient care data from contem-poranies of T.S. and C.B. have not been published.

Residency

Experiences

T.S. and C.B. admitted and treated 77 and 127

medical patients, respectively, during their 4

months of inpatient experience (Table 2). C.B. ad-mitted an average of 27 new patients per month, whereas T.S. averaged 19.3 patients per month.

Although the range of the length of stay of T.S.’s

patients was much narrower than that of C.B.’s

patients, the average patient stay of C.B.’s patients was shorter. Of T.S.’s patients, 50% stayed seven days or less, whereas 54% of C.B.’s patients had a

stay of three or less days. Of C.B.’s patients, 12% were hospitalized for only one day. Unfortunately, T.S.’s data do not describe his patients’ stay other than as less than 1 week.

Analysis of age group description of the patients of both residents indicates that C.B. saw a prepon-derance of young infants. Of her medical patients,

32.3% were less than 1 year of age, whereas only 12.5% of T.S.’s patients were in this age group. Of T.S.’s patients, 33% were referred to the HUP by private physicians, but only rarely did they attend the admitted patients. Staff physicians admitted

and were physician of record for 71.7% of C.B.’s

patients, whereas 38.3% were overseen by private physicians.

In Table 3, the most common primary diagnoses

for each resident’s panel of patients is shown.

Eleven different conditions accounted for 45.5% of T.S.’s total number of medical admissions and 63.8% of C.B.’s medical admissions. Patients with

respiratory disorders, asthma, pneumonia, and

bronchiolitis were the most common problems

en-countered by both trainees. Infections accounted

for 43.3% of C.B.’s admissions. Pneumonia,

bron-chiolitis, meningitis, “rule out sepsis,” and gas-troentenitis were the most common illnesses in this

category. Although T.S. did not organize his

medi-cal admissions into an infectious disease category,

27.8% of his 11 most common admitting diagnoses

were for infectious problems, compared with 34%

of C.B.’s 11 most common diagnoses. Children with

a history of premature birth accounted for 14.5%

of C.B.’s 55 patients with infectious diseases,

whereas 10.9% had underlying cystic fibrosis and

TABLE 2. Medical Patients

T.S. C.B.

1959-1960 1984-1985

Admissions (No. of patients)

Total 77 127

Per mo 19.3 27

Per admitting d i.9 2.7 Patient stay (d)

Length of stay 1-56 1-90

Average 9.5 8.3

%

of patients staying

id* 12

3d* 54

7d 50 71

19d 90 89

* Information not available from T.S.’s notes.

TABLE 3. Most Common Diagnoses at Admittance*

Diagnosis T.S. C.B.

(1959-1960) (1984-1985) Pneumonia Asthma Bronchiolitis Diarrhea Iron deficiency Glomerulonephritis

Sickle cell crisis Hepatitis

Croup

Meningitis Poisoning Rule out sepsis Chemotherapy Gastroenteritis Seizures

Poor weight gain

Urinary tract infection

* Results are numbers of patients.

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9.1% were oncology patients. Asthma was a more frequent cause for admission (15.7%) in C.B.’s era than T.S.’s (6.25%). Almost 9% of C.B.’s total number of medical patient admissions had under-lying malignancies contributing to their hospitali-zations. Similar information is not available from T.S.’s notes, but the number in this category is suspected to be low.

The impact of subspecialization on the training

experience is reflected in referrals for follow-up

after hospital discharge. In 1959 to 1960, 52% of T.S.’s patients were referred to the general pediatric clinic for their continued observation, whereas only 24% of C.B.’s patients were similarly referred. Only

9% of T.S.’s patients were referred to specialty

clinics; however, 37% of C.B.’s patients received their postdischarge care by subspecialists.

In Table 4, the outpatient clinic experience of the

two residents is seen. T.S. and C.B. only collected patient data during a few representative weeks of their outpatient rotations because the volume of outpatients they saw was high. C.B. recorded pa-tient data for 1 week during each of her three outpatient department rotations. She saw a total of 91 clinic patients in 3 weeks. T.S. collected data for 1 week. Only the distribution of his clinic patients’ diagnoses is available. C.B. saw a significantly

greater number of patients for well-child care. The

experience she had prescribing oral contraceptives

for adolescents was a skill not used by pediatric residents in T.S.’s day. A third of C.B.’s outpatient

experience was spent in the pediatric emergency

room where she saw an average of 40.7 patients per

week. The emergency room diagnoses ranged from

trivial upper respiratory tract infections to massive trauma. Approximately 40% of her emergency room patients had infectious diseases, whereas 30% had varying degrees of trauma. While working in the emergency room at night, C.B. was responsible for managing the Regional Poison Control hotline. Similar regional centers were not in existence in the late 1950s.

T.S.’s nursery experience included admission physical examinations of all babies, discharge phys-ical examinations of staff infants, and the diagnosis

TABLE 4. Outpatie nt Clinic Experience*

% of Patients No. (%) of Patients

Seen by T.S. Seen by C.B. Well-child care 30 47 (52) Respiratory illness 18

Asthma 3 (3)

Infectious disease 24 (26)

Skin problems 8 6 (7)

CNS problems 15 2 (2)

Contraception 2 (2)

Miscellaneous 29 7 (8)

* Number of outpatients seen by T.S. is not available.

and care of all sick newborns. He examined 813 full-term and 73 premature infants. Three full-term infants died. Causes of death were atelectasis,

erythroblastosis fetalis, and congenital heart

dis-ease. Eleven of the premature infants died. One had hyaline membrane disease, another atelectasis, and the rest, with a weight of less than 1,200 grams each, were described as having died of “immatu-rity.” OfT.S.’s newborns, 70 had morbid conditions, including congenital anomalies, surgical disorders, and hematologic problems such as Rh and ABO incompatibility.

C.B.’s neonatal experience was vastly different.

It included three rotations in the neonatal intensive

care unit and 1 month of mornings in the well-baby

nursery during one outpatient rotation, where she examined approximately three term infants per day. She admitted and cared for a total of 59 infants in the neonatal intensive care unit or an average of 4.5 patients per week. Of these infants, 78% were

premature. The most frequent primary diagnoses other than prematurity included respiratory dis-tress, congenital heart disease, and various other birth defects. After full term (22%), the most corn-mon gestational ages were 27 to 28 weeks (19%), and 33 to 34 weeks (15%). Of C.B.’s neonatal

inten-sive care unit patients, 12% were born at 24 to 26

weeks’ gestation. The length of stay in the neonatal

intensive care unit ranged from one to 305 days, with an average stay of 55.8 days. Death occurred in 11.9% of C.B.’s patients. Problems frequently encountered in the neonatal intensive care unit were hyaline membrane disease, birth asphyxia, bronchopulmonary dysplasia, patent ductus

arte-niosus, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumothorax, apnea and bradycardia, hypocalcemia, and hyperbilirubine-mia. As a first-year pediatric resident, C.B. per-formed arterial punctures for monitoring blood gas levels, umbilical artery catheterizations,

endotra-cheal intubations, lumbar punctures, and chest tube

insertions. She had experience in resuscitation of depressed newborns, use of ventilators, and writing of hyperalimentation orders. Invasive therapy was unusual 25 years ago.

C.B. also kept detailed records of surgical service

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ARTICLES 755 common surgical procedures were

ventriculopeni-toneal shunt revision, flexion contracture release, cleft lip or palate repair, inguinal herniorraphy and repair of hand anomalies, each accounting for 5% of the total.

A special subset of admissions were patients

undergoing cardiac catheterization. C.B. obtained an admission history, performed a physical exami-nation, and cared for 12 of these patients under the direction of the pediatric cardiology service.

DISCUSSION

Although we have no similar patient data from their peers, the residency experiences of these two pediatric trainees seem to be typical of other

resi-dents in their respective training programs. Despite

a separation in time of 25 years, the two programs

had similarities. Both were rigorous university

based residencies with similar time allocation in the first year for inpatient, outpatient, and nursery duties. Infectious disease, especially respiratory in-fections, accounted for the large percentage of the primary diagnoses of the patients of both trainees.

A number of differences between the two

pro-grams indicate that pediatric residency training has seen major changes during the past quarter century. First, the pediatric residency has increased in length. T.S. had 2 years of pediatric training, whereas C.B. had three. Most pediatric residency

programs have grown to include more trainees per class than they did 25 years ago. T.S. was one of

three residents, whereas C.B. was one of 1 1

first-year residents. The number of female pediatric residents has increased dramatically throughout the years. T.S. had one woman in his residency

class, whereas in C.B.’s class there were six female

residents.

The overall intensity of patient care has in-creased during this time. C.B., as a first-year

pedi-atric resident, followed-up patients in the pediatric intensive care unit and assumed their care when they were transferred to the pediatric ward. She had exposure to invasive monitoring, mechanical ventilation, and hyperalimentation. She had expe-nience with patients receiving peritoneal dialysis and those undergoing renal transplantation. 5ev-eral of her surgical patients had open heart surgery.

Pediatric intensive care units were extremely un-common 25 years ago, ventilator therapy was in its infancy, and routine hyperalimentation was not available.

The most marked changes have taken place in newborn care. C.B. cared for many preterm infants

who required a high level of sophisticated medical support. Of her patients, 39% were born at 30 or

less weeks’ gestation and weighed 1,500 g or less.

Most of the infants who died in the nursery

de-scnibed by T.S. weighed less than 1,200 g. His care of these low birth weight infants who managed to survive did not include the routine use of IV infu-sions, hyperalimentation, umbilical artery catheter-ization, ventilatony assistance, or chest tubes.

Erythroblastosis fetalis was diagnosed in a

signifi-cant number of T.S.’s nursery patients, whereas

C.B. never saw a single case. During her well-baby

nursery experience, C.B. examined approximately 60 term newborns, whereas T.S. examined more than 800 full-term infants. The emphasis in train-ing has shifted from normal newborn care to highly intensive support of immature and acutely ill new-borns.

Children with chronic diseases now constitute a large portion of pediatric hospital admissions: 68.5% of C.B.’s medical patients and 40% of her surgical patients had underlying chronic diseases such as cystic fibrosis, sickle cell anemia, and

cer-ebral palsy. Those with severe congenital

anoma-lies, metabolic disorders, or malignancies who

would have died in T.S.’s era are now surviving.

Children with repaired birth defects such as men-ingomyeloceles or congenital heart disease are liv-ing longer and often require numerous hospitaliza-tions for medical and/or surgical care. The fact that

ventriculoperitoneal shunt revision and flexion

contracture release were among the most common procedures performed on C.B.’s surgical patients attests to this. Pediatric oncology patients are ad-mitted frequently for chemotherapy or episodes of suspected sepsis. Former premature infants are

ad-mitted, often for medical problems stemming from

their early birth. Although the majority of C.B.’s

medical patients had chronic diseases, most of

T.S.’s patients had acute, self-limited illnesses.

During the last quarter of a century numerous

subspecialty clinics, in which follow-up care is given to chronic patients, have developed. Greater than a

third of C.B.’s patients were followed in such

din-ics, whereas less than 10% of T.S.’s patients at-tended subspecialty clinics on a regular basis.

In summary, comparison of the patient contacts

of these pediatric residents, separated by 25 years, shows that pediatric residency training has in-creased in length, trains larger numbers of resi-dents, especially women, and has evolved to include

a more intensive level of patient care that allows

for the survival and future care of many pediatric patients with conditions that were once fatal.

REFERENCES

1. Levine MD, Robertson LS, Alpert JJ: A descriptive study of a pediatric internship. Pediatrics 1979;44:986-990

2. Wallace PD, Silber, DL: Analysis of a straight pediatric internship. J Pediatr 1971;79:11O-113

3. Roghmann K, Pizzo P, Graham E, et al: The pediatric internship as a teaching technique: A comparison of learning experiences in five hospitals. Pediatrics 1975;56:239-245

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1988;82;752

Pediatrics

Christine R. Bryke, Walter W. Tunnessen, Jr, Thomas J. Scully and Frank A. Oski