Preparing Future Pediatricians: Making Time Count

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CONTRIBUTORS:Kenneth B. Roberts, MD,a_{and William V. Raszka Jr, MD}b

a_{Department of Pediatrics, University of North Carolina School of Medicine,}

Chapel Hill, North Carolina; andb_{Department of Pediatrics, University of}

Vermont College of Medicine, Burlington, Vermont

Address correspondence to Kenneth B. Roberts, MD, 3005 Bramblewood Drive, Mebane, NC 27302. E-mail: [email protected]

Accepted for publication Aug 22, 2011

doi:10.1542/peds.2011-2469

Preparing Future Pediatricians: Making Time Count

At the 2011 annual meeting of the Pedi-atric Academic Societies participants debated whether the duration of pedi-atric residency should be extended. Those favoring a longer residency ar-gued that there is more to learn now than 30 years ago and, because of reg-ulations curtailing resident work hours, less time in which to learn it. Their opponents argued that the pur-pose of residency is basic competence, not mastery, and there is still sufﬁcient time and ﬂexibility for residents to achieve basic competence. Moreover, adding time to the residency would be prohibitively expensive.

A proposal to extend residency is a sim-ple (and simplistic) solution to comsim-plex issues. In addition to the increase in medical knowledge in recent decades, the scope of pediatrics has widened, and subspecialization has progressed; learn-ers’ exposure to various aspects of pedi-atrics is now occurring, if at all, in dis-tinct and separate silos. Although setting basic competence, rather than mastery, as the outcome measure may seem re-assuring, deﬁning “basic competence” is challenging: does the term refer to a ba-sic level of competence in the vast breadth of pediatrics or to competence in a narrow basic “core” of pediatrics? This is a fundamental distinction for ed-ucators, future pediatricians, and the public, and there are implications for

length of medical school and residency training and breadth of experiences re-quired or necessary during training. The Association of American Medical Col-leges is undertaking a pediatrics rede-sign project for students interested in pediatrics that begins in the second year of medical school and progresses to the end of residency.1_{Transition from}

medi-cal school to residency and residency to practice will be based on competence rather than time. This effort is an exciting opportunity to create a true continuum of learning, but the results of the project will not be known for quite a while and, in the short-term, will only involve a small number of students. In the meantime, the vast majority of future pediatri-cians, and their teachers, face the daunting task of ensuring adequate preparation for residency after com-pletion of medical school and readi-ness for unsupervised practice after completion of residency in the cur-rent system. One approach to en-hancing the likelihood that future pe-diatricians are broadly competent is to better use opportunities available in the fourth year of medical school.

BACKGROUND

The minimum amount of time required

for each learner to achieve basic

com-petence in the broad discipline of

pedi-atrics is not known. Educators who

design curricula to ensure broad

com-petence face at least 2 obstacles. The

ﬁrst obstacle is lack of exposure.

Be-cause learning opportunities in the

various subspecialties have developed

as separate months (or “educational

units”), medical students and

resi-dents are likely to have little or no

ex-posure to children with conditions in 1

or more of the subspecialties. For

ex-ample, unless medical students and

residents commit 1 month to an

endo-crinology elective, their only exposure

to pediatric endocrinology is likely to

be a child admitted to the hospital with

diabetic ketoacidosis. Some specialty

opportunities, administered by

depart-ments other than pediatrics, are

par-ticularly “out of sight and out of mind,”

including areas identiﬁed repeatedly

as weaknesses by graduates of

pediat-ric residency training, such as ofﬁce

orthopedics.2

The second major issue is the lack of

oversight in the fourth year. Despite

the general consensus that medical

education needs to be reformed,3_little

attention has been directed toward the

fourth year.4_{In most medical schools,}

the time between completion of the

re-quired clerkships and graduation is

loosely organized and has few

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ments other than completion of a

sub-internship.4–6_{There is no national set}

of objectives or competencies that

de-scribe the fourth year, which results in

ﬂexibility (a good thing) but at the

ex-pense of direction and guidance. Some

schools require research or capstone

courses7_{; it is telling that 1 capstone}

course characterizes itself as “our last

chance to ensure competent resident

physicians.”8 _{Educators in a few}

spe-cialties, including surgery and

obstet-rics/gynecology, have published

rec-ommended fourth-year educational

courses for students interested in

those ﬁelds.9,10 _{Family medicine has}

identiﬁed core skills, competencies,

and goals for the fourth year.11_The

na-tional pediatric core curriculum

devel-oped by the Council on Medical Student

Education in Pediatrics (COMSEP) lists

the knowledge and skills expected of

advanced students.12 _{However, the}

format is not easily used by

educa-tors designing fourth-year

pro-grams, and the end result is that

stu-dents entering pediatric residency

do so with variable experiences and

levels of competence.13

RECOMMENDATION

The fourth year of medical school

should be a time for students to reﬁne

career choices and develop both

gen-eral and speciﬁc skills that they will

hone during residency and thereafter.

An approach to enhancing the

prepa-ration of future pediatricians is to

re-quire students interested in a

pediat-rics career to complete both a

subinternship and a minimum number

of months (eg, 3) of pediatric electives

that have speciﬁc objectives with

de-ﬁned competencies. The experiences

could be in subspecialty clinics,

com-munity practices, research

opportuni-ties in pediatrics, or advocacy

pro-grams. The exposure may help reﬁne

career choices. Currently, more than

two-thirds of students who enter

pedi-atrics residency have already decided

whether to pursue a career in primary

or specialty care, and approximately

three-quarters of them maintain their

commitment to that career choice in

their third year of residency.14_Those

who are planning a career in primary

care would beneﬁt from exposure to

areas of pediatrics (and related

disci-plines) that would supplement and

complement residency experiences;

those planning a career in a

subspe-cialty may use the time to help identify

which subspecialty is of particular

interest.

To address the growing need for more

speciﬁc objectives and clearly deﬁned

competencies for medical students

in-terested in the ﬁeld of pediatrics, the

Council on Medical Student Education

in Pediatrics (COMSEP) and the

Associ-ation of Pediatric Program Directors

(APPD) worked together to create a

subinternship curriculum in 2009.15

This curriculum has speciﬁc learning

objectives and learning modules as

well as assessment tools. The sub-I

curriculum is a good start, but more is

needed.

CHALLENGES

Students and educators may complain

that additional prerequisites place an

undue burden on medical students.

However, committing 3 months in

addi-tion to a subinternship to enhance the

training in one’s chosen ﬁeld would be

beneﬁcial and still allow for ﬂexibility

during the majority of the senior year.

The “burden” would be to construct a

rationale for the choice of experiences;

residency program directors might

choose to inquire about this rationale

as an assessment of the candidate’s

abilities as a self-directed learner.

Before 1988, residency recruitment

and selection was conducted largely in

the fall of the fourth year of medical

school, and match lists were due in

mid-November. In 1988, Robert

Peters-dorf, president of the Association of

American Medical Colleges, requested

deans to withhold their letters until

No-vember 1. The result was, in effect, an

extension of the period of medical

school that “counted” by an additional

2 to 3 months. Beginning in 2012,

how-ever, dean’s letters (ofﬁcially identiﬁed

as the Medical Student Performance

Evaluation) will be released 1 month

earlier, on October 1,16_thereby

reduc-ing the number of months in the fourth

year that “count” (ie, appear in the

of-ﬁcial report to residency programs).

As an unintended consequence, the

po-tential for greater underuse of the

valuable senior year will increase.

Developing competency-based

elec-tives will be challenging. Although the

core clerkship in pediatrics has quite

speciﬁc competencies,12 _{no speciﬁc}

national competencies exist for

fourth-year pediatric electives other than the

general inpatient subinternship.

Com-petencies for fourth-year experiences

will need to be developed, and

stu-dents will need to be assessed on the

basis of those competencies.

It should be noted that implementing

the recommendation that students

in-terested in pediatrics commit 3

months of their fourth year to

supple-menting and complementing

resi-dency training does not involve

over-coming 2 challenges common to most

educational innovations: securing

ma-jor funding and surmounting mama-jor

ad-ministrative obstacles.

CONCLUSIONS

The goal of pediatric medical

educa-tion should be to develop longitudinal

828 ROBERTS and RASZKA

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educational programs that entice

tal-ented young men and women to enter

the ﬁeld and to ensure that they are

well prepared to care for children at

the completion of their training and

thereafter. Deﬁning and better using

opportunities available in the fourth

year of medical school is a worthwhile

step in that direction and can be

imple-mented now.

ACKNOWLEDGMENT

We gratefully acknowledge Carol Car-raccio for thoughtful critique of an early draft of this manuscript.

REFERENCES

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16. Association of American Medical Colleges. Group on Student Affairs (GSA) steering committee: other discussion items—MSPE release date. Available at: www.aamc.org/ members/osr/updates/48812/reports_ gsasteeringcmte.html. Accessed August 4, 2011

FINANCIAL DISCLOSURE:The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.

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DOI: 10.1542/peds.2011-2469 originally published online October 10, 2011;

2011;128;827

Pediatrics

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Preparing Future Pediatricians: Making Time Count

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DOI: 10.1542/peds.2011-2469 originally published online October 10, 2011;

2011;128;827

Pediatrics

Kenneth B. Roberts and William V. Raszka, Jr

Preparing Future Pediatricians: Making Time Count

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