Resident Training and Education in the United States

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Resident Training and Education in the United States

Renee R. Jenkins, MD, FAAP

ABSTRACT. The Issue. Critical institutional and orga-nization issues affect the education of pediatricians, in-fluence their knowledge about child health disparities, and shape their attitudes and approaches to community pediatrics. Understanding the US graduate and postgrad-uate medical education system is necessary if critical and sustainable changes are to be made to ensure the capacity of pediatricians to respond to critical contemporary deter-minants of child health.Pediatrics 2003;112:752–754; resi-dent training, pediatric education, community pediatrics, resident education.

ABBREVIATIONS. APA, Ambulatory Pediatric Association; RRC, Residency Review Committee; AAP, American Academy of Pedi-atrics; FOPE II, Future of Pediatric Education II; ABP, American Board of Pediatrics.

T

here are several key US sources of guidance for the development of community pediatrics pro-grams in medical schools and residency train-ing:

• The Ambulatory Pediatric Association (APA) is a voluntary organization that has developed a set of in-depth educational guidelines related to resi-dency training in community pediatrics.1

• Pediatric Education in Community Settings2 _{is a}

monograph that describes community-based ap-proaches to resident education and can be used to guide the planning and implementation of com-munity pediatrics curricula.

• The Pediatrics Residency Review Committee (RRC) of the Accreditation Council of Graduate Medical Education is the body in the United States that establishes the standards and accreditation criteria for pediatric training. Residency Review Committee guidelines related to community pedi-atrics have evolved rapidly over the past decade to include requirements for community-based expe-riences in resident training.3

• The American Academy of Pediatrics (AAP) Fu-ture of Pediatric Education II (FOPE II) is one of the most current sources of recommendations on residency training.4

• The AAP Council on Medical Student Education in Pediatrics, a new organization aligned with the

chairs of pediatric training programs, has estab-lished a General Pediatrics Core Curriculum for medical school training.5

The APA training guidelines describe a compre-hensive set of topics that define the content of com-munity pediatric education from advocacy through environmental health and the pediatrician’s role in community settings (Table 1).1 _{The RRC program} requirements are not as prescriptive as those of the APA guidelines, but they do establish the require-ments for community experiences as a core compo-nent of residency curricula.3_{The community} experi-ences may include didactics but must involve residents in a community-based experience. The guidelines give examples of the types of experiences that a program can use to fulfill the criteria.

The AAP Section on Community Pediatrics sur-veyed training programs to determine what they were using as their community sites. Table 2 indi-cates that the sites most commonly used are private practice offices. By UK standards, these might not be considered community sites, but as US medical ed-ucation is primarily hospital based, these are consid-ered community sites.

The FOPE II report reaffirms the need for educa-tion in primary care pediatrics to be provided in ambulatory and community settings. It also de-scribes the roles that pediatricians will play in com-munity pediatrics in terms of the pediatrician gener-alist of the future.7,8 _{These roles include serving as} community consultants, population-based commu-nity medicine practitioners, school-based pediatri-cians, and providers for home-based medical care for chronically ill children.9

Once the content of community pediatrics curric-ula is defined, the next challenge is to delineate the attitude and skill sets to be acquired by trainees and how to measure this acquisition. What are relevant process and outcome measures? Previous measures have included only process criteria that have solely evaluated the existence of the experience in curricula

From the Department of Pediatrics, Howard University College of Medi-cine, Washington, DC.

Received for publication Mar 14, 2003; accepted Mar 14, 2003.

Address correspondence to Thomas Tonniges, MD, FAAP, American Acad-emy of Pediatrics, Department of Community Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007. E-mail: ttonniges@aap.org PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-emy of Pediatrics.

TABLE 1. APA Resident Training Guidelines in Community Pediatrics

Child in the Community

The Child in the Cultural, Ethnic, and Family Context The Child in Day Care and School Settings

Practice Management and Community Pediatrics Health Care Organization and Financing

Health Care for Children With Chronic Disease and Terminal Illness

Child Abuse, Neglect, Violence, and Substance Abuse Medically Underserved Children

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and resident participation. The demonstration of competency for accreditation purposes and more ac-tive measures of the success of the educational pro-cess are now being developed by the RRC.10 _The educational framework from which these commu-nity pediatrics competencies are being derived are outlined in the FOPE II report.4_{The framework} es-tablishes a competency-based educational system that is derived from the health care needs of the child in the context of family and community. The struc-ture of the health care system; advances in biomed-ical and psychosocial sciences; the evolution of our understanding of the social, political, economic, and environmental determinants of child health; and ad-vances in the application of new technology will influence how these needs are translated into the future roles of pediatricians. Using the broadest con-text of “community” to frame community pediatrics, the applicable RRC competency criteria—“actions that demonstrate an awareness of and responsive-ness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value”— can be adopted as the benchmark for resident and residency competencies.

Competencies can be measured more adequately at the level of individual programs. The community pediatrics program in San Diego, CA, published an excellent set of community pediatric competencies that include the trainee’s ability to access and use community services, appropriate identification and referral of victims of child abuse, and the ability to devise effective strategies for child advocacy (Table 3).11_{These are examples of the kinds of competencies} that would be expected of residents who complete community pediatrics rotations. Although the mini-mum requirement of the RRC is a 1-month commu-nity pediatrics rotation, some programs have ex-panded this and have grounded other required rotations (eg, child development and adolescent medicine rotations, continuity care) in community settings.

Inclusion of these competencies in the American Board of Pediatrics (ABP) certification process will be the final measure of the incorporation of community

pediatrics into the corpus of pediatrics. At the indi-vidual trainee level, the ABP is the organization that certifies pediatricians. Whereas the RRC defines the pediatrics training “process,” it is the ABP that es-tablishes the “outcome” criteria for board certifica-tion.12 _{There is a set of 10 to 12 competencies that} residency program directors use to judge the prepa-ration and readiness of residents to sit for the board examinations. These do not currently include com-munity pediatrics. If pediatricians are to be prepared to respond to the future health needs of children as they relate to community pediatrics, then the recog-nition by RRC of the importance of community pe-diatrics to the future of pepe-diatrics will need to be translated into competencies required by the ABP for board certification. As yet, no institution has in-cluded well-defined competencies related to the knowledge, attitudes, and skills required to translate an understanding of the social, political, economic, and environmental determinants of child health into child health practice, advocacy, and policy.

What are the challenges to establishing congruence between training curricula and resident competen-cies as they relate to producing pediatricians who are prepared with skills in community pediatrics? The first would be funding. A substantial portion of res-idency training is funded by the federal government through the hospital-based care provided by each resident. Hospitals apply for federal funds, called graduate medical education funds, through a for-mula that is based on the number of trainees and the volume of adult patient care provided in a hospital system. Until recently, children’s hospitals did not qualify to receive any graduate medical education funding. Before this time, freestanding children’s hospitals relied on their own funds to support resi-dency training. The funding is not full funding to this point. Even with current federal resources for chil-dren’s hospitals, federal support falls far short of the costs of training residents. The need for children’s hospitals to generate reimbursements through inpa-tient care conflicts with the time required for resi-dents to spend in the community to prepare them in community pediatrics. This presents a real dilemma to training programs throughout the United States.

A second challenge is how to measure compe-tence, as defined by knowledge, skills, and attitudes. One option, described for the United Kingdom, is a portfolio that demonstrates the type of cases that a trainee managed with evidence of how he or she made use of the community system. In the US sys-tem, few approaches have been developed to docu-ment the competencies of the pediatrician other than via the board certification examination. This results in an educational environment in which the board certification examination wields significant influence on curricula and the attention of residents. The crit-ical issue then becomes how to incorporate compe-tencies related to community pediatrics into the board certification examination.

The identification of funding and other resources to support, advance, and sustain educational inno-vation in the discipline of community pediatrics is the final challenge. Multiple public- and private-sec-TABLE 2. Most Common Community Sites Used by Training

Programs6

Private practice offices 81.5% School-based/school-related sites 70% Neighborhood health centers 65% Services for children who are disabled 56%

TABLE 3. Community Pediatric Competencies

Ability to access and use community services

Ability to integrate scientific data with family, cultural, social, and community factors in the community setting

Ability to identify and appropriately refer victims of child abuse Ability to communicate with nonphysician collaborators who

provide services to children

Knowledge pertaining to pediatricians’ role in the community Ability to prove age-appropriate health education

Ability to serve as a consultant to child-serving nonhealth system (school, day care center)

Ability to devise effective strategies for advocacy

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tor agencies and foundations have supported com-munity pediatrics innovations in the United States. These have included the Maternal Child Health Bu-reau and nonprofit organizations, eg, the Dyson Foundation.13

CONCLUSIONS

Progress is being made in the United States to affirm the need for community pediatrics training in the education of pediatric residents. Various US or-ganizations with responsibility for establishing stan-dards for pediatric training are defining the elements of community pediatrics for inclusion in curricula. The current challenge is to generate process and outcome measures of competencies in knowledge, attitudes, and skills related to community pediatrics and resident training experiences. Until these are well defined, core competencies in community pedi-atrics will not be incorporated into ABP certification examinations for pediatricians and thus will not be a priority focus for residency program directors. Also, given the current funding mechanisms for pediatric training that compensate for time spent in hospital-based rotations, there will be only limited success in efforts to expand community-based rotations.

The AAP and Royal College of Paediatrics and Child Health should work together to define the core competencies of community pediatrics and strategies for assessment of process and outcome measure-ments of these competencies. This will facilitate the enculturation of community pediatrics into pediatric training in the United States and the United King-dom and catalyze changes in residency funding equations to include community-based experiences as core rotations in training programs.

REFERENCES

1. Kittredge D, ed.Educational Guidelines for Residency Training in General Pediatrics.McLean, VA: Ambulatory Pediatric Association; 1996. Avail-able at: http://www.ambpeds.org/guidelines/index.cfm. Accessed November 5, 2002

2. DeWitt TG, Roberts KB, eds.Pediatric Education in Community Settings: A Manual.Arlington, VA: National Center for Education in Maternal and Child Health; 1996

3. Program Requirement for Residency Education in Pediatrics, General Pediatrics, Community (VB5) Accreditation Council for Graduate Edu-cation web site. Available at: http://www.acgme.org/req/ 320pr701.pdf. Accessed December 9, 2002

4. The Future of Pediatric Education II. organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century.Pediatrics. 2000;105(suppl):161–212

5. Council on Medical Student Education in Pediatrics (COMSEP), Gen-eral Practice Clerkship Curriculum web site. Available at: http:// www.unmc.edu/Community/comsep/curric/comcurr/gpcurtoc.html. Accessed November 5, 2002

6. Alpert JJ, Blodgett FM, Gargas DC, et al. A survey of community (out-of-hospital) sites used in pediatric training. Pediatrics. 1991;87: 719 –721

7. Cooper RA. Perspectives on the physician workforce to the year 2020.

JAMA. 1995;274:1534 –1543

8. Botash AS, Weinberger HL. Academia’s role in community access to child health.Pediatrics. 1999;103:1424 –1425

9. American Academy of Pediatrics, Committee on Community Health Services. The pediatrician’s role in community pediatrics.Pediatrics.

1999;103:1304 –1306

10. Accreditation Council for Graduate Medical Education Outcome Project web site. Available at: http://www.acgme.org/outcome/comp/ comphome.asp

11. Shope TR, Bradley BJ, Taras HL. A block rotation in community pedi-atrics.Pediatrics.1999;104:143–147

12. Program Director’s Guide for Evaluation of Residents in Pediatrics. American Board of Pediatrics web site. Available at: http:// www.abp.org/frtrack.htm

13. Anne E. Dyson Community Pediatrics Training Initiative, Dyson Foun-dation web site. Available at: http://www.dysonfounFoun-dation.org/ grants/grantset.html

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2003;112;752

Pediatrics

Renee R. Jenkins

Resident Training and Education in the United States

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2003;112;752

Pediatrics

Renee R. Jenkins

Resident Training and Education in the United States

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