A Survey of Pediatric Resident Training Programs 5 Years After the Task Force Report

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A Survey

of Pediatric

Resident

Training

Programs

5 Years

After

the Task

Force

Report

Howard

L. Weinberger,

MD, and Frank

A. Oski,

MD

From the Department of Pediatrics, Upstate Medical Center, Syracuse, New York

ABSTRACT. Twenty-nine pediatric residency training

programs responded to a survey with detailed descrip-tions of the scheduled rotations before and after the

Report of the Task Force on Pediatric Education. This

survey documented some changes in the overall structure of residency programming in that all programs demand 3 years of general pediatric training. Little if any changes

were noted in the traditional emphasis on inpatient and

neonatal training. Some changes in content area have been noted, namely a modest increase in the experiences in adolescent medicine. The survey failed to demonstrate any trend indicating increased emphasis on training ex-periences in the “new morbidity.” Pediatrics

1984;74:523-526; residency training, task force recommendations, new morbidity.

In its 1978 report, The Task Force on Pediatric Education outlined a number of recommendations for changes in residency training programs.’ Among the highlights of these recommendations were an extension of the duration of training in general pediatrics to 3 years, limitation of the subspecialty component to no more than one third of the total training time and to 6 months in any single subspe-cialty area, and expansion of training opportunities

in child development, in genetic counseling, in man-agement of children with chronic handicapping conditions, and in the “new morbidity.”2 This new morbidity was to include: behavioral problems of preschoolers, inadequate functioning in school, and problems relating to adolescents.

In the 5 years since this Task Force report was published, however, we are unaware of any attempt that has been made to monitor the effect of the report and to assess the changes in composition of residency training programs. This paper reports on an attempt to do just that.

Received for publication Sept 19, 1983; accepted Feb 1, 1984. Reprint requests to (F.A.O.) Department of Pediatrics, Upstate Medical Center, 750 E Adams St, Syracuse, NY 13210. PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the American Academy of Pediatrics.

MATERIALS

AND

METHODS

In January 1983, a letter was sent to chairpersons or program directors of 46 departments of pediatrics of varying sizes throughout the United States. Each program director was asked to return one copy of the department’s printed brochure describing the residency training program in 1982-1983 and one brochure describing the program in 1972-1973 (or as close to that year as possible).

A survey document was developed by us with the intent to extract information from the brochures about a variety of components of the programs such as: number of residents training each year, night call, salaries, vacation schedules, duration of train-ing in general pediatrics, subspecialties, electives, and opportunities for training in the new morbidity. It was soon evident that the brochures differed so greatly in the type of material and the details of the program descriptions, that it was not possible to collect the necessary data with this approach.

A follow-up letter was then sent requesting that the program director complete the survey document for the year 1982-1983 and the pre-1978 year closest to 1972-1973.

RESULTS

A total of 29 paired surveys were returned: six represented small programs (with <20 residents),

1 1 represented medium-size programs (20 to 35 residents), and

,

12 represented large programs (>36 residents).

Program

Size

All programs increased in size during the period of time reviewed by an average 23% to 50% (Table

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524 SURVEY

OF

PEDIATRIC

TRAINING

PROGRAMS

TABLE 1. Siz

dents) Before a

e of nd A

Program (Total fter 1978

Number of

Resi-Before 1978 After 1978

Av Av Range

Small Medium Large 9.8 23.4 46.5 14.2 9-18 31.0 22-36 55.5 45-77

Benefits

Salaries increased an average of 60% for PL-1 residents and 57% for PL-3 residents during the time period analyzed (Table 2).

Vacation schedules, in general, showed a gradual increase from PL-1 to PL-3 level and even though the post-1978 data demonstrated an increase in vacation time for all levels of trainees, the gradation from PL-1 to PL-3 remained essentially unchanged (Table 3).

Night Call

On the average, there was a slight decrease in the number of on-call nights when comparing the re-sults from pre- to post-1978 (Table 4). This finding was consistent for all levels of training. Nights on call were similar for all residency levels in about 20% of the programs. For PL-1 residents, only one program reported every other night on-call in the pre-1978 survey whereas 9/29 programs reported every fourth night on-call in the post-1978 survey.

Rotations

Inpatient experiences (ward plus newborn care) account for about half of the total program for all residents (Table 5). No discernible change is noted

in the most recent survey data when compared with the pre-1978 data (Intensive Care Unit experiences were included in the inpatient data especially for the pre-1978 survey). The larger the programs, the more time is allocated to in-hospital experiences, and again this finding is consistent before and after 1978. Overall, a decrease is noted in the number of months assigned to the ambulatory area for all but the large programs, and in these, less than 20% of the time was allocated to ambulatory experiences before and after 1978.

The majority of the 29 programs reported a nor-ma! newborn experience for PL-1 and PL-2 resi-dents. The care of the normal newborn is included in the ambulatory program in a number of programs in the post-1978 survey and included with the Neo-natal Intensive Care Unit data by other programs,

The total amount of time spent in newborn training

remains at or close to 6 months for all programs (before and after 1978).

Our survey revealed that PL-1 residents spend more time on inpatient experiences (average 5.4 months) than PL-2 residents (average 3.4 months) or PL-3 residents (average 35 months). PL-3 resi-dents spend less time in scheduled ambulatory ex-periences (average 2.1 months) than PL-1 residents (average 2.4 months) or PL-2 residents (average 2.6 months). Elective time accounts for an average of one-half month in the PL-1 year, about 2 months in the PL-2 year, and between 3 to 4 months in the PL-3 year.

Elective Versus Mandatory Programming in New

Morbidity

Before 1978, only 16 programs responding re-quired their residents to participate in continuity of care experiences, whereas this became almost a uniform requirement (24/29) for all resident levels after 1978 (Table 6). Although many of the pro-grams report that electives are available in the new morbidity, few programs require their residents to participate. Less than half (14/29) ofprograms now require experiences in adolescent medicine and this

is essentially unchanged (12/29) from the period before the Task Force Report. Most of these expe-riences appear to reflect exposure to hospitalized patients.

Child development rotations are now required by 13/29 programs (as compared with 1 1 in the pre-1978 survey) and elective opportunities are avail-able in an additional 7/29 programs.

Experiences in behavioral pediatrics or child psy-chiatry are now required in more programs (13/29) than before 1978 (6/29); but a specific rotation devoted to handicapping conditions is required in only 9/29 programs (unchanged before and after 1978).

DISCUSSION

A number of studies in the past 10 years have alluded to the phenomenon that pediatricians in practice are not comfortable in the management of problems that fall under the rubric of the new morbidity. Some of these studies served as the reference points for the Task Force on Pediatric Education which presented its final report in 1978.

Starfield et a13, in a survey of five different pe-diatric practices, found marked variability in the recognition and management of problems of a psy-chosomatic nature. In a further study, comparing generalists with pediatricians in the 1970s, Starfield4 outlined the dichotomy of the role of the pediatrician as a provider of primary care and sec-ondary care. In accompanying commentaries, Strain5 and St Geme6 attempted to reassure us that the changes in residency training that resulted from

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TABLE 2. Salaries of Residents by Size of Program

PL-1 Residents PL-3 Residents

Before After Before After

1978 1978 1978 1978

Small $10,800 $17,000 $12,700 $19,800

Medium 11,300 18,100 13,400 20,600

Large 11,100 18,400 12,600 20,700

Av $11,200 $18,000 $13,100 $20,500

TABLE 3. Residents’ Vacation Schedules (Weeks)

PL-1 Residents PL-2 Residents PL-3 Residents

Before After Before After Before After

1978 1978 1978 1978 1978 1978

All programs 2.18 2.62 2.85 3.27 3.12 3.46

Range 1-4 1-4 2-4 2-4 2-4 2-4

TABLE 4. Residents’ Night Call Schedule*

PL-1 Residents PL-2 Residents PL-3 Residents Before After Before After Before After

1978 1978 1978 1978 1978 1978

Av 3.1 3.3 3.4 3.8 4.1 4.5

Range 2-4 3-4 2.5-5 3.2-5 3-6 3-7

* Values shown are schedule every “number” days.

TABLE 5. Total Time Spent (in Months) During 3-Year Residency

Small Programs Medium Programs Large Programs Before After Before After Before After

1978 1978 1978 1978 1978 1978

Inpatient 10.5 11.3 12.4 11.5 13.4 13.3

Outpatient 7.7 7.4 8.5 7.3 6.8 6.8

Newborn/Neonatal 6.6 5.5 6.2 5.9 6.2 6.2

Intensive Care Unit

Subspecialty 2.8 3.7 3.7 3.8 1.5 2.3

Electives 6.9 7.0 5.2 6.4 6.4 6.0

TABLE 6. Elective Versus Mandatory Programming in ‘New Morbidity’

Elective Mandatory Before After Before After

1978 1978 1978 1978

Continuity of care 3 1 16 24

Child development 8 7 11 13

Child psychiatry/ behavioral pediatrics 10 7 6 13

Adolescent medicine 4 8 12 14

Orthopaedics 12 16 1 1

Handicapping condition 8 9 7 9

Skin problems 13 16 1 3

Ethics . .. 2 1 1

Genetic counseling 8 13 3 6

Extramural primary care 13 15 5 9

the Task Force Report are preparing current resi-dents to deal more effectively with these problems than their generalist colleagues and than pediatri-cians trained before the Task Force Report.

The Task Force Report recommended changes in pediatric residency training programs that would

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526 SURVEY

OF PEDIATRIC

TRAINING

PROGRAMS

were ultimately planning for careers in the general practice of pediatrics or a hospital-based subspe-cialty.

The assumption has been made that once the Task Force Report was presented, the training of all residents in American residency training pro-grams would be adjusted to fill the gaps identified in the Task Force Report. We believe that ours is the first attempt to document whether this has indeed occurred.

The sample size of our survey (29 programs re-sponded) represents approximately 12% of all ac-credited pediatric residency training programs in the United States. As part of a recent survey of resident work load in 113 pediatric training pro-grams, J. W. Littlefield looked at program size, on-call frequency, elective time, and vacation time (Report to the Association of Medical School Pe-diatrics Department Chairmen, mc, March 1983). The results of our sample survey compared very closely with Littlefield’s on these items. There is no reason to suggest that the other items covered in our survey would not be representative of all the US training programs.

Our survey found that indeed all programs are now 3 years in length and the pyramid system, so common a decade ago, has been virtually eliminated in pediatric training programs. The total number of residents in training has risen commensurate with the general increase in class sizes in medical schools in the 1970s.

No evidence has been found in our survey, how-ever, to support the hypothesis that any major changes have occurred in the content of the training programs. It is quite possible that this survey has been performed too soon to detect such changes. Although nearly all programs now offer some form of continuity experiences for their residents, it is likely that there is considerable variability in these experiences. The traditional weighting of residency training toward hospital-based experiences persists. Fully half of all the residents’ training time is spent on inpatient wards and newborn services, whereas less than 20% of time is allocated to ambulatory programming. If anything, ambulatory experiences have decreased slightly, and Neonatal Intensive Care Unit experiences have increased since the

1978 Task Force Report.

Most programs adhere to the letter of the Task Force recommendations regarding limiting subspe-cialty experiences to no more than one third of the 36-month total residency program. However, be-cause the normal newborn experience is often in-cluded as part of the ambulatory program in the post-1978 survey data, it is likely that the spirit of the Task Force recommendation limiting any one subspecialty area to 6 months is being stretched by

many programs.

Ambulatory training experiences tend to decrease from the PL-1 to the PL-3 year although electives increase (almost none in the PL-1 year to an aver-age of 2 months in the PL-2 year and almost 4 months in the PL-3 year). It is possible that some of this elective time is spent in ambulatory pro-gramming, especially for those residents who are planning primary care careers. There is no way to document that from our survey, although approxi-mately half of the programs did offer electives at the PL-2 and PL-3 levels in the primary care set-tings in their respective communities.

Finally, our survey failed to demonstrate any uniformity in the post-1978 survey in residency training experiences in the new morbidity. Some programs explicity offer fixed rotations in child development, in behavioral pediatrics, and in the care of children with chronic handicapping condi-tions. These represent the minority of all programs

responding. Others offer these experiences as elec-tives only, and there does not seem to be much difference before or after the Task Force Report. The only exception is the increase in both elective and mandatory experiences in adolescent medicine, but even there, less than three quarters of all pro-grams have this rotation as a requirement or elec-tive for PL-3 or PL-2 residents.

CONCLUSIONS

This survey is the first attempt to determine the effect of the Task Force Report of 1978 on the duration and content of Pediatric Residency

Train-ing in the United States. Although, all programs

are now 3 years in duration, the traditional struc-turing of the content area has not changed dramat-ically in the 5 years since the report was published. If this survey is representative of all training pro-grams, these findings should give reasonable pause to those who believe that practice patterns of pe-diatrics in the 1980s will be significantly different from that found by Starfield in the early 1970s. Only time will tell.

REFERENCES

1. Task Force on Pediatric Education. The Future of Pediatric Education. Evanston, IL. American Academy of Pediatrics, 1978

2. Haggerty, RJ, Roghmann KJ, Pless lB. Child Health and

the Community. New York, John Wiley and Sons, 1975, pp 94-116

3. Starfield B, Gross E, Wood M, et a!. Psychosocial and psychosomatic diagnoses in primary care of children. Pedi-atrics 1980;66:159

4. Starfield B: Special responsibilities: The role of the pedia-trician and the goals of pediatric education. Pediatrics

1983;71:433

5. Strain JE: Pediatrician’s role in primary health care.

Pedi-atrics 1983;91:441

6. St Geme JW Jr: Challenge ofpediatric education. Pediatrics

1983;71:442

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1984;74;523

Pediatrics

Howard L. Weinberger and Frank A. Oski

Report