Twenty-Five
Years
of Residents:
What and
Where
Are They Now
Catherine
DeAngelis,
MD; Ann Duggan,
ScD;
and Frank
Oski,
MD
From the Department of Pediatrics, The Johns Hopkins Medical Institutions, Baltimore,
Maryland
ABSTRACT. To evaluate the effectiveness of our program in meeting the subsequent career needs of our graduates and to describe their professional experiences as a micro-cosm of pediatrics, a survey was completed of the 419 pediatricians who had completed the Harriet Lane Resi-dency Program at The Johns Hopkins Hospital between 1960 and 1984. Overall, the 326 respondents found the program to have been effective in the areas they deemed appropriate to be taught in residency years. In decreasing order, the chief resident, fellow house officers, and full-time faculty were rated to have had the greatest teaching effectiveness. The women respondents were less likely to be married (76% vs 89%), had fewer children on average (1.2 vs 2.31), missed more work, and were more likely to enter postresidency training (89% vs 78%) than the men. Of all respondents, 73% reported being certain of their career goals during residency and 77% of those reported
a reasonable similarity with current positions. More than 93% reported being satisfied with their current careers, and 87% would still choose pediatrics. They are generally well reimbursed financially, with academician salaries matching those of private practitioners 10 years after completing residency and surpassing them, slightly, thereafter. This information provides much food for thought in preparing tomorrow’s pediatricians. Pediatrics 1990;85:10-16; residency training, pediatrics education.
Both internal and external forces have greatly
altered the field of pediatrics during the past few decades. Current important issues include the
in-flux of women into the profession, growing
recog-nition of the importance of general pediatrics as a teaching and research focus, and differences
be-tween academic and nonacademic practice.
Resi-dency programs must respond to the demands gen-erated by these forces. To gain some insight from
Received for publication Dec 2, 1988; accepted Mar 15, 1989.
Reprint requests to (C.D.) CMSC 2-124, The Johns Hopkins
Hospital, Baltimore, MD 21205.
PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the
American Academy of Pediatrics.
which alterations might be generated, we surveyed
a 25-year population of graduates from The Harriet
Lane Pediatric Residency Program at The Johns
Hopkins Medical Institutions.
The objectives of this study were (1) to evaluate
the effectiveness of our program in meeting gradu-ates subsequent career needs and (2) to describe
our graduates’ professional experiences as a micro-cosm of pediatrics in general.
METHODS
The study population was defined as all graduates
of The Harriet Lane Program who had completed their residencies between 1960 and 1984 and who
had spent at least their second or third years in the program. Study data were collected from a
struc-tured mail questionnaire. The first mailing occurred in July 1986, and 6 months later another copy of the survey was sent to all those who had not
re-sponded to the first. In the interim between
mail-ings, telephone contact was attempted to reinforce the mailed request for survey participation and to
update old address information.
Information concerning several areas was solic-ited: (1) demography including age, gender, year of
residency completion, marital status, number of
children, and time missed from work and reasons
for it; (2) status during residency including
non-MD doctoral degrees held, certainty of career goals,
effectiveness of various types of teachers, methods,
and the program in general, and research pursuits;
(3) postresidency training by types and board sta-tus; and (4) current professional status including
work satisfaction, salary, site of current practice, academic status, and time distributions for patient care, teaching, administration, bench research, din-ical research, and other activities.
RESULTS
Of the 419 pediatricians who had spent at least their second or third years in the the Harriet Lane Program between 1960 and 1984, 326 (78%) com-pleted the survey. We were unable to locate 17
(4%), 4 (1%) were deceased, and 72 (17%) did not respond. The response rates by 5-year increments were 63% (1960 to 1964) and 81%, 80%, 78%, and 86% for 1980 to 1984, respectively.
Demography
Of the 326 respondents, 82 (25%) are women; this compared with 28% of the total sample who are women. Of note, during the 1960s, 15% of our residents were women compared with 53% between 1980 and 1984. Of all respondents, 86% were mar-ned (89% ofthe men and 76% ofthe women). They had an average of 2.0 children (2.3 for the men and 1.2 for the women). Only 20% of the respondents had no children (44% of the women and 12% of the men); 37% had three or more children (20% of the women and 43% of the men).
Throughout the years, 26% ofthe women and 2% of the men had missed more than 3 months of work in total; 6% of the women but no men had missed more than 12 months, and one woman had missed more than 2 years. The difference was primarily,
but not totally, related to pregnancy and children.
For women, but not for men, marriage was
signifi-cantly positively associated with missing work.
Status
During Residency
Overall, the number of residents who entered the program with a non-MD doctoral degree or who achieved it during the residency was 5.8%. This percentage generally increased throughout the years with the percentages in 5-year increments being 2.2% (1960 to 1964) and 4.2%, 2.8%, 9.5%,
and 10.6% for 1980 to 1984, respectively.
During their residencies, 73% of respondents re-ported being very or at least somewhat certain of their career goals. Only 77% reported a reasonable similarity between their current positions and their goals during residency. The more certain the goal was during residency, the more likely that the cur-rent position would be similar to it (P < .001). There was generally no difference in this area among the 5-year incremented groups covered by this study.
Of the various teaching “methods” mentioned,
the chief resident was reported by the largest pro-portion (81%) of respondents to have had the great-est effectiveness; this was followed by fellow house officers (78%), full-time faculty (63%), floor
attend-ing faculty (54%), and case conferences (52%). All other “methods” were rated by fewer than 50% of the respondents as being effective. With few excep-tions, there was a close correlation between effec-tiveness and exposure (Table 1).
The areas of instruction in which the faculty
were reported to have been helpful were basic facts of clinical medicine (88%), applying organic medi-dine to practice (86%), organizing diagnostic and therapeutic regimens (86%), translating scientific findings into practice (67%), teaching and/or role modeling good physician/patient relationships (60%), and principles of comprehensive care (56%).
In contrast, the areas of instruction in which faculty were reported not to have been helpful were use of
ancillary services (79%), applying behavioral devel-opmental medicine and psychiatry to practice (70%), knowledge and skills of research (65%), and
recognizing and managing social problems (61%). Despite the perceived lack of research training, 36% of the respondents had been involved during
their residencies in scholarly projects that had re-sulted in publications.
Postresidency
Training
Overall, 82% of respondents went on to
postres-idency fellowships (89% of the women and 78% of the men). As shown in Table 2, the most popular areas of subspecialization during the 25 years were (in decreasing order) hematology/oncology, neona-tology, public health/preventive medicine, allergy!
immunology, neurology, endocrinology, academic general pediatrics, genetics, and infectious diseases.
TABLE 1. Teaching Methods: Proportion of Respond-ents Reporting Great Exposure and Great Effectiveness
Great Great
Effectiveness Exposure
(%) (%)
Chief resident 81 85
Fellow residents 78 92
Full-time faculty 63 63
Full-time floor attending phy- 54 54
sician
Electives 49 19
Case conferences 52 46
Grand rounds 45 71
Subspecialty clinics 44 46
Saturday conferences 38 40
Didactic lectures 28 30
Continuity clinics* 23 22
Part-time faculty 22 17
Part-time floor attending phy- 19 19
sician
Community hospital teaching 19 19
Research conferences 8 8
Non-MD health professionals 7 6
TABLE 2. Areas of Study Among Gradua of Residency.
tes Obtaining Postresidency Training, by Year
1960-1969 1975-1984 %Change*
(n = 86) (n = 120)
(%) (%)
Allergy/immunology 9.3 7.5 -19
Anesthesiology/pediatric intensive care 0.0 6.7 t
unit
Behavioral pediatrics 8.1 4.2 -48
Cardiology 7.0 5.8 -17
Dermatology 1.2 1.7 +41
Developmental pediatrics 4.6 6.7 +46
Endocrinology 10.5 2.5 -76
Gastroenterology/nutrition 1.2 5.0 +317
General pediatrics and adolescent med- 1.2 13.3 +1008
icine
Genetics 10.5 2.5 -76
Hematology/oncology 10.5 13.3 +27
Infectious diseases 4.6 6.7 +46
Metabolic diseases 8.1 0.0 -100
Neonatology 8.1 11.7 +44
Nephrology 3.5 2.5 -28
Neurology 4.6 10.8 +135
Pharmacology 2.3 2.5 +9
Psychiatry 5.8 1.7 -71
Public health/preventive medicine 14.0 10.0 -29
Pulmonology 2.3 5.0 +117
Other 8.1 4.2 -48
* Change in proportion from 1960 to 1959 (time A) to 1975 to 1984 (time B), calculated
as: (Time B % - Time A %)/Time A %.
t Because time A% equals zero, change is undefined.
However, comparing subspecialty choices of the
1975 to 1984 graduates with those of the 1960 to 1969 graduates revealed substantial increases in the following fellowships: academic general pediatrics
and adolescent medicine (increased by 1008%),
gas-troenterology/nutrition (317%), neurology (135%),
and pulmonology (117%). Marked decreases were found in metabolic diseases (decreased by 100%),
endocrinology (76%), genetics (76%), and
psychia-try (71%).
Of the total respondents, 85% had passed their pediatric board examinations, and 37% had
subspe-cialty board certification. Of those who had corn-pleted the program before 1980, 91% had passed
pediatric board examinations and 44% had passed
subspecialty board examinations.
Current
Professional
Status
Of the graduates, 49% practice full-time based in
hospitals, 27% are in private practice, 9% work in health maintenance organizations, 6% are in fel-lowships, 5% work for local or state health depart-ments, and 5% work for federal agencies. A total of 48% hold full-time and 15% have part-time aca-demic positions.
More than 93% ofthe respondents reported being
satisfied with their current positions, and there was
no difference in satisfaction between academicians
and nonacademicians. Ninety-two percent would
still choose medicine, and 87% would still choose pediatrics, specifically, as a career. Those in
full-time academics were most likely to choose medicine again (94.9%) as compared with those in part-time academics (83.7%) and those not in academics
(90.9%).
The overall mean distribution of time spent for all respondents in their current positions was as follows: patient care 41%, teaching 18%, bench research 14%, administration 13%, clinical research
9%, and all other activities 5% (Fig 1). The
distri-bution of types of patient care provided was acute
illness 33%, consultation 31%, chronic illness 20%,
and health maintenance 15%.
Our graduates are generally well reimbursed fi-nancially with 21% of the total earnings netting more than $100 000 and 19% earning less than
$50 000 annually. To put this in perspective, 43%
of the respondents had been out of residency fewer than 10 years. Of special note is that full-time academician salaries match those of private
prac-titioners by 10 years after completion of residency
and surpass them slightly after 25 years (Fig 2).
Ninety-one percent of respondents believed that they had been adequately or very well trained for
Patient Care Teaching 18% Other 5% Iinical Research 9% Basic Rel 14% Administration 13%
Fig 1. Mean distribution of time in current position.
Thousands 100 80 60 40 20 0 1965-69 1970-74
Year of Residency
-
Fuiltime Academic All OtherFig 2. Median annual income of full-time academics vs all others.
their training to be barely adequate or inadequate spend more time in administration, 23% vs 12% (P < .05) and less time in patient care, 30% vs. 44%
(P < .04), than those who reported adequate train-ing. There were no differences in teaching, basic research, or clinical research time between these groups. The 9% who reported inadequate training
are all satisfied or very satisfied with their current
positions.
The adequacy of residency training for various
professional activities as perceived by those who
spend at least 25% of their time in those activities
is shown in Table 3. Most judged their training for patient care and teaching to have been adequate
and would give a high priority for those activities
to be taught in residency training. Far fewer judged their training in basic research (39%), administra-tion (44%), and clinical research (51%) to have
been adequate. Even so, these areas, particularly
basic research, were assessed to be high priority teaching items for residents by only a minority of respondents.
The respondents noted that they currently spend little time with procedures they frequently
per-TABLE 3. Curre
of Training, and Training
nt Level of Effort, Perceived Adequacy Priority Assessment for Residency
At Least 25% Training Effort Currently Adequacy*
(n = 326)
High Priority* Patient care Teaching Basic research Administration Clinical research
186 (57) 97
104 (32) 92
75 (23) 39
62 (19) 44
36 (11) 51
98
83 12 Not asked
43
* Denominator is the number listed in column one, ie,
those who currently devote more than 25% effort to the
activity.
formed during their residencies. As examples, 76%
never suture wounds, 73% never perform lumbar punctures, and 67% never start intravenous
infu-sions.
DISCUSSION
Demography
The overall and increasing percentages of women pediatric residents in our sample reflect the na-tional picture.’ In the early 1980s, 43% of pediatric residents nationally were women compared with our 53%. According to the American Board of
Pe-diatrics, currently, 51% of pediatric residents na-tionally are women compared with 68% of our
current residents.
This increasing influx of women into pediatrics
has ramifications related to time lost from work because of pregnancies, children, and other family-related issues. In our sample, 13 times more women
than men (26% vs 2%) missed more than 3 months
of work, and 6% of women had missed more than 1 year. This was directly related to marriage for women but not for men. Furthermore, most of the time lost for women was due to pregnancy. Accord-ing to LeBailly and Brotherton,2 women pediatri-cans are more likely to report career interruptions, ie, stopping work or taking nonmedical jobs, than
are men. In 1988, 34% of board-certified women
pediatricians reported career interruptions corn-pared with 6% of men. Among those reporting career interruptions, 70% of women reported that they were due to child rearing and 20% due to their
spouses careers. Clearly, career interruptions and
the concomitant potential for working fewer hours
must be considered when estimating the number of
pediatricians necessary to meet the medical needs of children.
LeBailly and Brotherton,2 who reported that 93% of board-certified male pediatricians compared with 78% of women were married. Men, in their study,
had an average of 2.6 children compared with 1.7 for women. Their slightly higher figures are
prob-ably reflections of their sample population being older than ours, which was skewed slightly toward
younger pediatricians. In their study, 26% of board-certified women pediatricians had no children corn-pared with 44% of our graduates, and 9% of male
pediatricians vs 12% of our male graduates had no children.
The average number of children per family in the United States has been between 1.7 and 1.9 since the early 1970s.3 Not surprisingly, pediatricians love children and have more than the general popula-tion. Even with career constraints, women pedia-tricians come close (the Harriet Lane Program graduates) or match (pediatricians, in general) the general population in terms of average number of children. This is interesting considering the con-flicting roles of women physicians that challenge successfully combining their professional and per-sonal lives.48
Careers and Goals
A substantial proportion of our residents entered
with or earned a second doctoral degree during the residency period. The 10.6% of our 1980 to 1984 residents with a doctorate is probably higher than the average for all pediatric residents and most likely reflects the program’s emphasis on academics
and research.
The fact that approximately 1 of 4 respondents
had not been certain of their career goals was not surprising considering the numerous options open to pediatricians and the various role models they have had. This is further reflected by 1 of 5 now having positions that are not similar to their goals during residency. Consider that 9% currently work in health maintenance organizations, which were barely in existence during most of the training time covered by this study. A certain amount of flexibil-ity is healthy for being able to take full advantage of potential changes in many realms.#{176}
Teaching Methods
Clearly, the chief residents have been effective as teachers. This reflects the philosophy in our, and probably most, programs that the chief resident is responsible for organizing and attending most con-ferences, making daily formal and informal rounds, choosing attending physicians, and being general
consultant and often confidant to the residents.
The majority of our chief residents have had several years of postresidency training and/or experience before becoming chief. During the time covered by this study, almost all of them had served as outpa-tient chief resident the year before chief residency. The other teaching personnel and methods speak for themselves and are probably generalizable
na-tionally. The lack of adequate and effective teach-ing in psychosocial, behavioral pediatrics nationally
is well documented,102 and this area should receive prompt attention in all pediatric programs.
Although there are no published data available, it seems that the 36% of our residents who pub-lished during their residencies represents a high percentage. This is especially surprising because no elective rotations were offered to our residents until 1978, after the majority of respondents had corn-pleted their residencies. Furthermore, many of the respondents had been required to work an every-other-night on-call schedule during residency; this call schedule also was changed in 1978. It would be interesting to determine if electives and an every-fourth-night schedule would result in more or fewer residents publishing. Is it the nature of the resident, the nature of the program, or both that results in publications during residency?
Postresidency Training
The fact that 4 of 5 of our graduates entered postresidency training is not surprising because the faculty role models and the not-so-subtle philoso-phy of the teaching program is academically on-ented. It also is interesting to note the changes in subspecialty training that have occurred through-out the years. The most popular areas overall, and those with increasing popularity, generally reflect the presence of strong faculty and/or the develop-ment of strong programs in those areas.
The most preferred areas of subspecialty training themselves are reflections, at least to some degree, of changing service needs throughout time. For
example, the 982 PL-II residents who applied to
take the board examinations in pediatrics in 1985 reported the following areas of subspecialty choices: neonatology, 9.4%; cardiology, 3.1%; allergy-im-munology, 2.5%; hematology, 2.2%; infectious dis-eases, 2.1%; pulmonology, 2.0%; critical care med-icine, 2.0%; emergency medicine, 1.9%;
general pediatrics as their area of choice, but, un-fortunately, this was not broken down by the per-centage choosing fellowship training vs practice in this area.
The vast majority (91%) of our graduates who
are eligible have completed their pediatrics board
examinations. Furthermore, 44% have completed their subspecialty board examinations. The latter figure is high considering that many graduates chose subspecialties for which no board examina-tions are available. To help put this in perspective, in 1978 22. 1 % of all pediatricians nationally were either eligible for or had passed subspecialty board
examinations.13
Current Status
The satisfaction of 93% of our graduates with
their current position and the fact that 92% would again choose medicine in general and 87% would choose pediatrics in particular as careers compares
well with national data. In 1978, 70% of
pediatri-cians, nationally, found their profession to be sat-isfying, and 96% would again choose medicine as a career. Furthermore, 91% of academicians and 82%
of nonacademicians would chose to become a pedia-trician again.13 Both studies provide evidence that medicine, and pediatrics specifically, is a satisfying career.
That 48% of our graduates are full-time and 15%
part-time academicians is another reflection of the program’s philosophy. Although we could find no published data with which to compare our program with others, in 1978, 23% of pediatricians nation-ally practiced academic pediatrics.’3
The academic bias of our respondents must be
considered when contemplating the overall mean distribution of their time as shown in Fig 1. Fur-thermore, the distribution of types of patient care provided is skewed toward consultative or second-ary-tertiary care with only 15% devoted to health maintenance.
The financial status of respondents is
surpris-ingly good, especially for the full-time academicians
who match the income of nonacademicians 10 years
after residency and slightly surpass it 20 years after. To help put this in perspective, in 1978
academi-cians earned an average annual income of $36 812 compared with $45 760 for practitioners.’3 The rel-ative financial well-being of our graduate academi-cians might be, at least in part, a reflection of the number who became chairpersons or division chiefs. We can document that at least 16 of our graduates since 1960 have become chairpersons. Also, aca-demic salaries, in general, seem to have increased substantially during the past decade.
It is reassuring that 91% of the respondents reported having been at least adequately trained for their current positions and that the other 9% spend more time in administration and less time with patients than the satisfied group. It would be diffi-cult to argue that residents should spend time learn-ing how to be administrators. As shown in Table 3, the graduates agree that high priority should
con-tinue to be given to training residents for patient
care and teaching. It is interesting to note that a sizable majority of the clinical researchers believe
that high priority should be given to teaching resi-dents about clinical research, but bench researchers
do not believe the same about teaching bench
re-search during residency. This might reflect the thought that there is relatively little time to teach residents about research, and clinical research is
much closer to their usual activities than is bench
research.
Few of our graduates spend much time with
pro-cedures they frequently performed during resi-dency. Because this is probably generalizable for all residency programs, it makes educational sense to
have nonphysicians performing most of the
proce-dures. This also might become necessary if, or perhaps when, new rules for resident work hours are enacted. The amount of time spent performing
these procedures probably goes well beyond that necessary for the resident to acquire the technical skill, per Se, and the important lessons of dealing with inflicting pain on others, acquiring
self-confi-dence with concrete evidence of accomplishment and others that will impact on patient care through-out a physician’s career.
In summary, the respondents found the program
to have been effective, with most of the training being at least adequate. In areas such as bench research where the training was rated as
made-quate, residency was not viewed as the appropriate
time for such training.
Although our graduates are most prepared for
academic practice, much of their professional and
personal experiences can be viewed as a microcosm
of pediatricians, in general, and provide much food for thought.
REFERENCES
1. Report of the Task Force For Women in Pediatrics.
Pedi-atrics. 1983;71(suppl):688-692
2. LeBailly 5, Brotherton S. Career Paths of Men and Women
in Pediatrics: Descriptive Fundings From the Survey on Pediatric Careers. Working paper 15. Elk Grove Village, IL: American Academy of Pediatrics; 1988
3. Margolis ML. Mothers and Such: Views ofAmerican Women
and Why They Changed. Berkeley, CA: University of Cali-fornia Press; 1984:270
Med. 1981;304:1161-1162
5. Franco K, Evans CL, Best AP, et al. Conflicts associated
with physician’s pregnancies. Am J Psychiatry. 1983;
140:902-904
6. Hems M. Medicine and motherhood. JAMA.
1983;249:209-210
7. Madelson C, Notman M, Lowenstein P. The practice
pat-terns, life styles, and stress of women and men entering medicine: a follow-up study of Harvard medical school
grad-uates from 1967 to 1977. J Am Med Wom Assoc.
1979;34:400-406
8. Shapiro J. Children during residency: it’s easier if you’re a man. JAm Med Wom Assoc. 1981;36:227-231
9. Kappy MS. The pediatric residency program of the future.
Am J Dis Child. 1987;141:945-947
10. Report of the Task Force on Pediatric Education: The
Future of Pediatric Education. Evanston, IL: American Academy of Pediatrics; 1978
11. Engel GL. The biopsychosocial model and medical
educa-tion. N EngI J Med. 1982;306:802-805
12. Cohen MI. The Society for Behavioral Pediatrics: A new
portal in rapidly moving boundary. Pediatrics. 1984;73:791-798
13. American Academy of Pediatrics, Committee on Manpower.
Projecting pediatric practice patterns: a survey by
Pediat-rics. 1978;62:625-665
NEVER TAKE ANYTHING FOR GRANTED
Julian Bigelow, an electrical engineer who helped John von Neumann build the Johnniac computer at the Institute for Advanced Study in Princeton in the early 1950s, tells a story about how when he drove down from Cambridge, Massachusetts, to be interviewed by von Neumann for the job, he met with the great man at his home in Princeton. As the story goes, there was a large dog romping on the lawn, and as von Neumann opened the door to let Bigelow in, the dog ran into the house and started running from room to room, sniffing everything in sight in the manner commonly practiced by dogs everywhere. Busy in their discussion neither von Neumann nor Bigelow paid much attention to these canine antics for quite awhile, but finally von Neumann’s curiosity
overcame his courtly Central European manners and he asked Bigelow if he
always traveled with his dog. Bigelow replied, “It’s not my dog. I thought it was yours.” Such are the presuppositions that pervade every aspect of human activity, science (and scientists) being no exception.
From Casti JL. Paradigms Lost. New York, NY: Wm Morrow; 1989.
