EDUCATION 541
Good teaching is set in many diverse frameworks; here is the framework for one aspect of
the educational program of the Department of Pediatrics, University of Washington.
PEDIATRIC
RESIDENCY
PROGRAM
By Robert W. Deisher, M.D.*
G.F.P.
D
URING the past 10 to 15 years, the type of practice carried on bypediatni-cians has been undergoing a change. There
are fewer seriously ill children requiring
long-tenll treatment and follow-up since
many of tile common infectious diseases of
childhood are detected early and, because
of modern methods of treatment, prevented
from becoming serious. Although
pediatni-cians have fewer patients who require
hos-pita! care, this is balanced by the fact that
there is Il increasing use of the pediatrician
for health supervision or “well child care.”
Parents are becoming more aware of the
need for supervision of tile child’s physical
and emotional growth and development
through tile extensive attention given this
in popular everyday literature and by the
fact the pediatrician himself is now
en-couraging this more than formerly.
This change in pediatric practice is being
reflected gradually in the type of
pnepana-tion given the pediatrician in his residency
training. When one thinks of the
tremen-dous amount of knowledge available
regard-ing normal growth and development and
of the growing importance of the field it is
evident that real knowledge in this area
cannot be obtained quickly and without
effort. Therefore it is of sufficient
impor-tance to be included in routine residency
traimlmg. There is no question that the
resi-dent needs much more of his time spent in
the hospital caring for seriously ill
ciii!-dren than in the well-child area of
pedi-atries. It is to be hoped however that the
well-child training lie is given will be of
such nature as to provide him ample
op-Porttlnity to work Vitil well children and
parents. Thereby he may learn about
nor-0 Assistant Professor of Pediatrics and Director,
University of Washington Child Health Center, Seattle, Washington.
mal development and behavior at various
ages and also become familiar with the
parents’ problems relating to these ages and
stages of development.
If such opportunity for experience in
well-child work is provided, the
pedia-trician just beginning practice will not feel
that this is of relatively little importance
nor be annoyed with the amount of time
it requires. Also he will not have a tendency
to concentrate on only physical aspects of
the well-child visit thereby neglecting a
total appraisal of the child. Likewise, the
newly established practitioner with
ade-quate background will be aware of the role
expected of him, as a specially trained
per-son, in the community. Schools, social
agen-cies concerned with children, as well as
various parent groups, turn to him very
frequently for advice and help in solving
common problems. He should be aware of
the fact that schools are concerned with
many of the same problems that he is, that
there are community agencies which deal
with children and that knowledge of them
may be extrelnely useful to him in his
prac-tice. The fact that there are non-medically
trained people such as psychologists,
teachers, nutritionists, and social workers
who have a great deal of knowledge
con-eerning children and who often can work
effectively with him is important for him
to know.
The pediatric residency program in
Se-attle, which is under the direction of the
Department of Pediatrics of the University
of Washington School of Medicine, has
tried to meet some of tile resident’s needs
in these areas by offenimig an opportunity
for pediatric residents to spend 3 months,
or in selected cases 6 months, in a
non-hospital setting where the emphasis is
542 DEISHER - PEDIATRIC RESIDENCY PROGRAM
himself and the community in which he
lives.
The University of \Vashington Child
Health Center provides a facility in which
this type of training can be given, inasmuch
as it is a clinic devoted to the care of non-ill
children and staffed with people
nepre-senting a variety of professional fields. Also
it bias numerous relationships with many
community agencies dealing with children.
The clinic has been described previously in
an article dealing with the training
pro-gram for medical students.’ It bias seemed
to be an ideal place in which the resident
could gain a type of experience which
would prepare him more adequately for
present day pediatric practice.
CONTENT OF PROGRAM
The resident’s experience begins with a
1 week period of orientation to growth and
development in its broadest meaning.
Van-ous aspects of health supervision are
dis-cussed and demonstrated by the staff
pedia-tnicians. Methods for evaluation of physical
growth are reviewed. Anticipatory
gimid-ance is stressed. The resident is made aware
of the physician’s responsibility to discuss
witil each mother the child’s expected
be-ilavior relative to his age and the most
likely areas in which problems may arise.
By this method some of the difficulties
re-sulting from the mother’s lack of
under-standing of normal child development can
be prevented. The specific need for making
mothers aware of the most likely hazards at
various ages is emphasized in order to
pre-vent accidents.
Opportunity is given for members of the
Center staff to give adequate interpretation
of their fields and their functions in this
muitidisciplined clinic. The staff physicians
make a clear amid thorough interpretation of
the physician’s place in such a group and
his function as a member of a clinical team.
Without this the resident’s inclination may
the beginning frequent referrals of patients
with various problems be made to other
staff members in order to see how others
with special training and skills handle
them. The contribution of the public
health nurse iii the bionic wilere a mother
has much anxiety about the care and
han-dung of her newborn infant; advice the
nu-tritionist bias for a mother who is
expenienc-ing difficulty in getting her child to eat or
who refuses to drink milk; the social
worker’s approach to the mother who is
unable to set any limits for her 2-year-old
or who has an overly aggressive child are
examples of the type of help which can be
contributed by others on the clinic staff.
Usually the resident has riot had much
previous experience with tilese situations.
It is obvious that this de)endency on others
silould not continue indefinitely, inasmuch
as the pediatrician will not be abbe to rely
on such persons in his practice, but that this
should be for him a learning experience. He
is encouraged to discuss each referred case
with the person to whom he has referred it
in order to see how the problem is handled
and to see how lie might in the future
pro-ceed with simiiiiar ones. As he gains more
experience and knowledge he is expected
to do less referring to others and to assume
more responsibility himself.
Special emphasis is given to the type of
interview necessary in the well-child visit
inasmuch as these patients do not tome
with either chief complaint on present
ill-ness. It is pointed out that by making
sys-tematic inquiries into important areas such
as eating, sleeping, elimination, and general
development and activity, the physician
helps mothers to bring up questions which
they might not ask spontaneously. In turn,
the resident will become familiar with the
great variation in normal children at
dif-ferent ages.
After the orientation period the resident
participates in the regular program of the
appoint-EDUCATION 543
each ease but as the resident becomes more
experienced. the time of appointments is
decreased to 30 niinutes. If there are special
areas iii which parents need help, they may arramige for the parents to come in alone
later for discussion of the situation.
Resi-dents follow the same cases for the
duna-tion of their training experience. At the
end of each day the staff meets to review
the cases that have been seen during the
day. This gives the residents opportunity
to discuss cases about which they have
questiomi on for the staff to point out areas
in which difficulties are most likely to
oc-cur. Discussion is held concenmiing the
etiol-ogy of problems encountered and also ways
of best handling them. This not only is
valuable for the resident from the
stand-point of learning but also demonstrates
effective teamwork.
Besides the regular program certain
special features are planned for the
nesi-dents. They attend seminars on subjects
re-lating to children. These are conducted by
staff members-pediatricians, child
psychia-trists, psychologist, nutritionist, social
worker, dentist, and others. Some are for
medical students as webb as the residents,
some for the residents alone. The resident
participates in the medical student training
.program 2 afternoons each week. His
func-tion is to help teach the medical students
about normal growth and development by
discussing with them cases they have seen.
There is discussion of nursery school and
opportunity provided for the resident to
visit in a nearby nursery school and observe
the activities being carried on for different
age groups.
Arrangements are made throughout the
3-month period for each resident to visit
community agencies dealing with children
in order that the residents may become
familiar with each agency, its functions and
especially its potential use to a practicing
pediatrician. Among some of the agencies
visited are juvenile court, adoption agency,
child welfare department, state Crippled
Children’s Prograni, child guidance clinic,
Spastic Preschool Climiic, public school for
handicapped children, state institution for
retarded children, hearing and speech clinic
and family service agency. The agencies’
re-actions to these visits have been most
en-thusiastic. The personnel have been very
pleased with the opportunity to familiarize
young physicians with the functions of their
agencies.
Arrangements are made for each resident
to spend 1 day in a nearby public school
where a demonstration school health
pro-gram is in operation.’ After this introduction
to philosophy, content and procedures of the
school health service and the robe of the
physician, he is assigned to the service,
for 1 day in an elementary school, 1 in a
junior high school. During this time he
works independently of the other physicians,
conducting conferences with parents,
teach-ers and nurses regarding problems
pre-sented by certain school children.
Time is made available during the entire
period for attendance at the pediatric grand
rounds and the weekly teaching conference
of the pediatrics department in the
ciii-dren’s hospital.
The program has been in operation 2
years and has been uniformly well received
by the residents. Almost all have begun
their affiliation with a great deal of question as to the importance of such an experience
to a pediatrician but subsequently have felt
that it has given them a much broader
pedi-atric outlook and interest in the field.
REFERENCES
1. Deisher, Robert W. : Use of the child health
conference in the training of medical
stu-dents. PEDIATRICS, 1 1:538, 1953. 2. Deisher, Robert W. : Issaquah school health
