Pediatric Residency Training: Ten Years After the Task Force Report

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Pediatric

Residency

Training:

Ten

Years

After

the

Task

Force

Report

876 PEDIATRICS Vol. 90 No. 6December 1992

Esther H. Wender, MD*; Polly E. Bijur, PhD*; and W. Thomas Boyce, MD

ABSTRACT. A sample of 3000 pediatricians who had

completed their residency training in 1978 or later were

surveyed regarding the perception of the adequacy of

their residency training in specific aspects of pediatric

practice and in a number of subspecialty areas. The

survey was almost identical with the one that formed the

basis for the American Academy of Pediatrics Task Force

on Pediatric Education report in 1978. The results

re-vealed relatively little change in the high rates of per-ceived “insufficient training” in all the areas of pediatrics

described as “underemphasized” in the Task Force

re-port. However, those residents who received their

train-ing during the second half of the 10 years since the Task

Force survey reported significant improvement in the

previously underemphasized areas of developmental and

behavioral pediatrics and adolescent medicine. Results

also revealed a significant increase in the number of

pediatricians who identify either a subspecialty interest

or subspecialty practice in developmental or behavioral

pediatrics. The increase in pediatric subspecialists and

the improved training experience since 1984 indicate that

the Task Force report may have had a positive impact on

residency training in developmental and behavioral

pe-diatrics. Pediatrics 1992;90:876-880; pediatric education,

developmental pediatrics, behavioral pediatrics, pediatric

residency training, adolescent medicine.

In 1978 the Task Force on Pediatric Education of

the American Academy of Pediatrics published a

report entitled The Future of Pediatric This

report was based, in part, on a survey of a total

sample of 7000 pediatricians, which inquired about

the nature of their pediatric practice and their

percep-lion of the adequacy of their training experience. The

Task Force report highlighted what it called the

“un-deremphasized areas in pediatric residencies.”19

The most prominent of these underemphasized areas

were the biosocial and developmental aspects of

pe-diatrics and adolescent medicine. Other

underem-phasized areas included community pediatrics,

clini-cal pharmacology and toxicology, handicapping

con-ditions and chronic illness, and medical ethics. The

major recommendation emanating from this report

was that teaching programs place greater emphasis on the biosocial aspects of pediatrics and adolescent

health.

From the Depaent of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; and Department of Pediatrics, University of California at San Francisco.

Received for publication May 4, 1992; accepted Jun 1 1, 1992.

Reprint requests to (E.H.W.) Division of Developmental and Behavioral Pediatrics, Schneider Children’s Hospital, Long Island Jewish Medical Cen-ter, New Hyde Park, NY 11042.

In the 14 years that have transpired since the

publication of this widely publicized report, those

concerned about pediatric education have questioned

the impact of these recommendations on pediatric

training. In 1984, Weinberger and

Oski2

surveyed 29

pediatric training programs. They asked the training directors to complete a survey, describing the specifics of the training program during the 1982-1983

aca-demic

year and a pre-1978 year. The survey requested

information regarding the types of rotations and

spe-cifically requested information regarding training

op-portunities addressing the “new morbidity.”3 Minimal

changes occurred in training programs after 1978, in comparison with pre-1978 training, though continuity

experiences greatly increased. There was a modest

increase in adolescent medicine electives and an

in-crease in mandatory experience in child psychiatry or

behavioral pediatrics, but almost no change in

man-datory rotations.

In 1984 Zebal and Friedman4 reported on a survey

of behavioral pediatric training. Questionnaires were

sent to all 246 accredited pediatric residency training

programs, and a 60% (n = 147) response rate was

obtained. Although there are no data prior to the Task

Force report for the purpose of comparison, they

found that 49% of the programs had formal

behav-ioral pediatric training and an additional 38% offered

some training. Only 13% offered no training.

In 1987, Comerci et al5 reported on a survey of

pediatric programs; the survey specifically addressed

changes in resident training in adolescent medicine. Program directors were asked to provide detailed descriptions of adolescent medicine training for 1978

and 1983. A sample of recent residency program

graduates were also surveyed for information

regard-ing their clinical training experiences in adolescent medicine. Sixty-three of the program directors sur-veyed could be matched to surveys from recent

pro-gram graduates. These authors reported a 10%

in-crease in the number of adolescent wards, a 33%

increase in the number of adolescent clinics, and a

29% increase in programs having a block of time

devoted to adolescent medicine training. It is of inter-est, however, that despite the increase in services devoted to adolescents, the total percentage of resi-dents receiving training had not changed significantly between 1978 and 1983.

Finally, Bryke et al6 reported on changes in pediatric

residency training between 1959/1960 and 1984/

1985. This report was based on detailed records kept by two residents in training, one each during these two time periods. Besides the obvious increase in the length of residency training and the increase in the

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The original questionnaire used to survey pediatricians for the Task Force of Pediatric Education project was modified to eliminate questions that were no longer applicable. For example, the question was eliminated that asked pediatricians whether they favored recommending three core years of post-medical school training as a prerequisite for Board Certification. In addition, one question was added to ascertain specific information about the nature of

devel-opmental and behavioral pediatric practice and the degree to which such services were adequately reimbursed. Approximately 90% of

the questionnaire was identical with the one that formed the basis

of the Task Force report. This slightly modified survey instrument

was mailed to a random sample of 3000 pediatricians obtained from the member rolls of the American Academy of Pediatrics. All members of the sample surveyed completed their pediatric resi-dency training on or after the 1978-1979 academic year. Three follow-up mailings yielded a total response rate of 70% to the current questionnaire, which compares favorably with the 53% response rate in the original Task Force survey. A copy of the survey instrument may be obtained by writing the first author. Chi-square analyses were performed between the results of this questionnaire and the original survey.

Excluded from the approximately 2100 initial responses were 3 1 5 responses from Academy members who were still in residency training. This left a maximum number of usable responses of 1785. Table 1 shows the distribution of those sampled according to the year residency was completed. As these figures show, the majority of the sample had recently completed residency training.

Table 2 shows the number and percentages of those who had completed training and were currently in private practice, salaried

TABLE 1. Distribution of Sample by Year Residency

Com-pleted

CNS, not significant. percentage of female residents, these detailed

descrip-tions document the increased exposure to patients with chronic conditions and the increased intensity

of exposure as measured by the total number of

patients cared for.

The present study addresses the training issues raised in the Task Force report by conducting a similar

survey on a different sample of pediatricians who completed pediatric residency training after publica-tion of the 1978 Task Force report. Both the original

survey and this subsequent questionnaire addressed

pediatricians’ perception of the adequacy of their

training and their perceived competency in a number of areas of pediatric practice. Because the current survey largely duplicates the Task Force survey,

com-parisons can be made between the perception of

training then (1977) and now (1989). This report

focuses primarily on perceptions of change in pedi-atric residency training in the areas of developmental and behavioral pediatrics and adolescent medicine.

METHODS

Year Residency n (%)

Completed

1978-1979 236 (13)

1980-1981 350 (20)

1982-1983 357 (20)

1984 835 (47)

TABLE 2. Current Professional Situation

Professional This Survey, Previous Task

Situation n (%) Force Survey,

%

Private practice 830 (52) 53

Salaried practice 475 (28) 22

Academic 294 (18) 18

practice (institutional settings or salaried clinic practice), and pri-marily academic positions compared with the figures for the Task Force survey. Except for a modest increase in recent graduates who are in a salaried practice, the figures are quite similar. The total numbers in the following tables differ slightly because of missing data in some analyses.

RESULTS

Both surveys requested pediatricians to identify areas of special interest or subspecialty. Table 3 com-pares the percentage of pediatricians identifying spe-cial-interest areas in the two surveys. Developmental and behavioral pediatrics was not a label used in the Task Force survey. Instead, three areas of special interest were listed that relate to developmental and behavioral pediatrics, namely, “the handicapped child,” “behavior and psychosocial,” and “growth and development.” This same terminology was employed in the follow-up survey to facilitate comparison. Chi-square analyses reveal significant differences in 5ev-eral areas. There was a particularly striking increase in subspecialty interest in six areas, including all three that relate to developmental and behavioral pediat-rics: the handicapped child (P < .01), behavior and psychosocial (P < .01), and growth and development

(P < .001). A significant increase was also seen in

pulmonary (P < .001), critical care/intensive care unit

(P < .001), and adolescence (P < .001). A significant decrease was seen only in allergy and immunology

(P < .01) and hematology/oncology (P < .05).

Table 4 shows the percentage of pediatricians who identified a special interest in areas of developmental/ behavioral pediatrics cross-tabulated with their iden-tification as general pediatricians with a specialty interest or as subspecialists. This table further mdi-cates an increased interest in this area of pediatrics in the 1 0 years since the Task Force survey, both by general pediatricians and especially by subspecialists.

TABLE 3. Subspecialty or Special Interest

.

This Survey

(n

=

922), % of

Responses

Previous Task Force Survey

(n

=

893),

%of

Responses

P*

Allergy and immunology 10 15 <.01

Cardiology 6 8 NS

Hematology/oncology 5 8 .05

Nephrology 2 4 NS

Neonatal/perinatal 23 23 NS

Endocrinology 4 4 NS

The handicapped child 1 1 7 <.01

Pulmonary 8 4 <.001

Gastroenterology 3 3 NS

Critical care/intensive 10 2 <.001

care unit

Neurology 3 3 NS

Adolescence 13 8 <.001

Behavior and psychoso- 15 10 <.01

cial

Community medicine 4 4 NS

Dermatology 2 1 .05

Genetics 4 4 NS

Growth and develop- 13 7 <.001

ment

Infectious disease 8 6 NS

Other 7 4 .01

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878 RESIDENCY TRAINING

TABLE 4. Percent of General Pediatricians With Specialty

In-terests and Subspecialists With Interest in Developmental-Behav-ioral Subspecialities

Characterization of Patient Care Activities

General Pediatrics

Area With Special In- Subspecialty terest

Previous This Previous This Survey Survey Survey Survey

Behavior and psy- 16 24 <5 8

chosocial

Handicapped child 9 3 <5 10

Growth and de- 9 17 <5 9

velopment

The follow-up survey contained a question

assess-ing characteristics of clinical activity by those

pedia-tricians who identified a special interest in

develop-mental/behavioral pediatrics (n = 224). Because this

question

did

not appear on the Task Force survey, no

comparisons are available. Table 5 indicates that the

major clinical activity in this area of special interest

falls into the categories of assessment, counseling,

and case coordination. The prescription and

manage-ment of psychotropic medication were endorsed by

just over one third of those providing therapy. Table

6 shows the percent of clinical practice devoted to, in

contrast to the percent of income derived from, this

aspect of practice. These figures reveal a

dispropor-tionately low percentage of derived income compared with the time devoted to practice for those

pediatri-cians who devoted only a portion of their practice to

this subspecialty area.

Both the original Task Force questionnaire and this

follow-up survey queried pediatricians’ perceptions

regarding the sufficiency of participatory experience

and learning opportunities in specifically designated

aspects of pediatric residency training. Table 7

com-pares the responses on this survey with those on the

Task Force questionnaire. In the Task Force survey

more residents considered their experience

“insuffi-cient,” in comparison with this more recent survey, in

the areas of longitudinal vs episodic care (P < .001),

care of adolescents (P < .001), and community

pro-grams such as schools and juvenile facilities (P = .05).

This survey revealed an increase in the perception of “insufficiency” of residency training in the areas of

learning disability, attention deficit disorder, and

mental retardation (P < .001); extramural ambulatory

care such as private practice (P < .001); and care of

patients with chronic diseases (P = .05). These data

were then reanalyzed in the current survey by

divid-ing the population of pediatricians into those who

completed their residency from 1978 through 1983

and those who completed their residency in 1984 or

later, since modifications in training programs in

di-rect response to the Task Force report would have

taken time to accomplish. The results of this analysis

are shown in Table 8. These results reveal that in

several areas there was a significant reduction in those

who found their training insufficient among the more

recently trained pediatricians compared with those

who completed training from 1978 through 1983.

TABLE 5. Nature of Clinical Activity in D

ioral Specialty Practice

evelopmental/Behav-Nature of Clinical Activity %Eborg

Assessment

Extended or family interview 80

Developmental testing 53

Counseling 56

Family therapy 13

Individual psychotherapy 8

Psychotropic medication 35

Case coordination 62

Hypnosis, relaxation, or biofeedback 7

TABLE 6. P

come Derived Fr

ercent of Practice Devoted to, and Percent of In-om, Developmental/Behavioral Subspecialty

%of %of

Practitioners Practitioners

Endorsing

Endorsing Amount of

Amount of Practice

Derived Income

<10% 35 61”

10-25% 23 12

25-50% 12 7

50-.75% 6 3

>75% 22t 22t

* Includes 26% who derived 0 income from subspecialty.

t

Includes 16% who derived 100% income from, and devoted 100% of practice to, subspecialty.

TABLE 7. Sufficiency of Participatory Experience a

Opportunity During Pediatric Residency”

nd Learning

Residency

Expe-rience

Was

“Insuffi-Aspect of Pediatrics cient

. Task This Force Survey Survey Valuet

Longitudinal as opposed to 36 50 <.001 episodic care

Care of adolescents 55 66 <.001

Care of patients with

Chronic diseases 22 18 .05

Learning disability, atten- 60 40 <.001

tion deficit disorder, mental retardation

Psychosocial or behavior 55 54 NS

problems

Interviewing and counseling 39 41 NS

Ambulatory care

Within medical center 10 1 1 NS

Extramural (eg, private 59 45 <.001

practice)

Administration (office man- 88 89 NS

agement)

Child advocacy (poor chil- 49 51 NS

then, racial minorities, abused children, etc)

School health 65 64 NS

Community programs (nurs- 70 73 .05

ery schools, juvenile

courts, etc)

Dentistry 76 78 NS

wValues are percentages. t NS, not significant.

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TABLE 8. Perception of Experienc

by Year Completed Training”

e and Learni ng Opportunity

1978-1983 1984 _Pt

Longitudinal as opposed to episodic 41.6 29.1 <.001

care

Care of adolescents 59.1 50.9 <.001

Care of patients with

Chronic disease 19.9 23.6 .06

Learning disability, attention def- 63.5 56.1 .002

icit disorder, mental retardation

Psychosocial or behavior prob- 60.0 50.1 <.001

lems

Interviewing and counseling 43.4 33.3 <.001 Ambulatory care

Within medical center 1 1 .7 8.4 .03

Extramural 59.5 58.6 NS

Administration (office management) 89.9 85.9 .01

Child advocacy 53.3 43.8 <.001

School health 68.3 60.8 .001

Community programs 74.3 64.5 <.001

Dentistry 73.4 78.9 .008

CValues represent percent who considered their experience and learning opportunity “insufficient.”

t NS, not significant.

These areas include longitudinal care (P < .001); care of adolescents (P < .001); care of patients with learn-ing disabilities, attention deficit disorder, and mental retardation (P = .002); care of patients with

psycho-social or behavior problems (P < .001); interviewing and counseling (P < .001); office management (P =

.01); child advocacy (P < .001); and school health (P

= .001). Interestingly, there was a significant increase in perceived insufficiency of training by the more recently trained pediatricians in the area of dentistry and a trend toward greater perceived insufficiency of training in the care of patients with chronic disease.

DISCUSSION

The main thrust of the Task Force on Pediatric

Education’s 1978 report was to highlight what it

referred to as underemphasized areas of pediatric

residency training. These underemphasized areas

were identified by pediatricians’ perception of the adequacy of their residency training in several se-lected aspects of pediatrics. The Task Force urged an increase in the emphasis on the biosocial and devel-opmental aspects of pediatrics and in adolescent med-icine, two of the areas where residency training was perceived to be most deficient. This reassessment of pediatricians’ view of their training in the 1 0 years after the Task Force report indicates a steady improve-ment in the perception of adequacy of training in adolescent medicine and an improvement in several areas related to developmental and behavioral

pedi-atrics during the most recent half of that time interval. Despite these definite improvements, the level of dissatisfaction with exposure and training in both of these fields remains high. More than 50% of those surveyed still consider inadequate their training and

exposure to the care of adolescents; learning

disabil-ity, attention deficit disorders, and mental retardation; and psychosocial or behavior problems. By contrast, two thirds of the most recently trained pediatricians consider their training sufficient in the important skills of interviewing and counseling.

In contrast to these high levels of perceived made-quate training in developmental and psychosocial areas, there has been a striking increase in pediatri-cians who identify either a special interest or a sub-specialty in areas of developmental and behavioral pediatrics. These changes may be the result of the infusion of support for residency training in

devel-opmental and behavioral pediatrics from 1976

through 1983 by the W. T. Grant Foundation.4’79 Additional support for training pediatricians in the behavioral sciences came from the Robert Wood John-son Foundation’s support for the general pediatric

academic development program and the clinical

scholars program supported by the W. T. Grant

Foun-dation. More recently, grants from Maternal and

Child Health (US Department of Health and Human

Services) have supported fellowship training in de-velopmental and behavioral pediatrics leading, in part, to sharp increases in the number of fellowship

training programs in this field. The Society for

Behav-ioral Pediatrics, in the process of developing a fellow-ship training directory, has recently identified 54 sep-arate fellowship training programs. Given the time it takes to make major shifts in training, one of the clearly identified problems is the availability of ade-quately trained pediatric subspecialists who can de-vote attention to this aspect of pediatric residency training.4 The postgraduate pediatric training in the behavioral sciences and the increase in fellowship

programs has, it is hoped, aided in this process. The present survey gives some indication of the nature of clinical activity in developmental and be-havioral pediatric practice. Eighty percent of those interested in this aspect of practice conducted ex-tended or family interviews, two thirds provided case coordination, and more than half provided counseling or conducted developmental testing. Thirty-five per-cent reported prescribing psychotropic medication.

The current survey also documents one of the primary

problems encountered in the practice of develop-mental and behavioral pediatrics, namely the lack of appropriate reimbursement for time spent. This prob-lem was particularly noticeable for those pediatricians who devoted only part of their time to this area of special interest. While 35% of the sample devoted 10% or less of their time to this area of special interest,

61 % received 1 0% or less of their income from this aspect of practice. It is also of interest, however, that 16% of those interested in developmental and behav-ioral pediatrics devoted 100% of their time to (and

received 100% of their income from) this type of

practice.

There remain a number of limitations to what can be learned from this or the previous survey. This type of survey can only tell us how pediatricians perceive their training experience. Of greater importance is the nature and quality of their actual practice. It may be, for example, that the ambiguous and subjective

qual-ity of clinical problem-solving in the developmental

and behavioral area promotes a perception of made-quate knowledge. Many pediatricians describe an im-provement in their sense of confidence in this aspect of pediatric care that comes with time and experience. Although this report focuses primarily on the issues

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880 RESIDENCY TRAINING

of pediatric residency training in

developmental-be-havioral pediatrics, it is also of interest that adolescent

medicine continues to fare well in comparison with

prior eras of pediatric training. The Society of Ado-lescent Medicine conducted a survey of changing

emphasis on adolescent medicine just 5 years after

the Task Force Report.5 The conclusions of that study

were mixed, but generally less optimistic than those

supported by this study, which revealed a

continu-ingly significant increase in the perception of

im-proved training in adolescent care issues.

CONCLUSIONS

Pediatricians who received their residency training

since the report of the Task Force on Pediatric

Edu-cation in 1978 indicate a perception of improved

training in both developmental and behavioral

pedi-atrics and adolescent medicine. This perception of

more adequate training particularly applies to those

who completed their residencies from 1984 to 1989.

There is also a significant increase in the number of

pediatricians who identify their area of special interest

or subspecialty practice in the area of developmental

and behavioral pediatrics. Despite these changes,

there continues to be a high percentage of

pediatri-cians who believe that their training in developmental

and behavioral pediatrics and adolescent medicine is

insufficient.

The current trends are nonetheless encouraging and

may reflect the impact that the Task Force and its

report have made on pediatric education.

ACKNOWLEDGMENTS

This work was supported, in part, by a grant from the William

T. Grant Foundation.

We thank the American Academy of Pediatrics for providing access to current membership files and to the data from the previous Task Force on Pediatric Education survey. We thank Michael I. Cohen, Chairman of the Department of Pediatrics at The Albert

Einstein College of Medicine, for his ideas and support. R. James McKay, Jr. MD, provided another link to the original Task Force on Pediatric Education survey and report and prepared the sup-porting letter that accompanied the present survey.

REFERENCES

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

2. Weinberger HL, Oski FA. A survey of pediatric resident training pro-grams 5 years after the Task Force report. Pediatrics. 1984;74:523-526

3. Haggerty RJ, Roghmann KJ, Pless lB. Child Health and the Community. New York, NY: John Wiley and Sons; 1975:94-96

4. zebal BH, Friedman SB. A nationwide survey of behavioral pediatric residency training. IDev Behav Pediatr 1984;5:331-335

5. Comerci CD, Witzke DB, Scire AJ. Adolescent medicine education in pediatric residency programs following the 1978 Task Force on Pediatric Education report. JAdoles Health Care. 1987;8:356-364

6. Bryke CR, Tunnessen WW Jr. Scully TJ, Oski FA. Pediatric residencies: differences between 1959/1960 and 1984/1985. Pediatrics.

1988;82:752-755

7. Felice ME, Friedman SB. Teaching behavioral pediatrics to pediatric residents: the state of the art and description of a program. I Dev Behav Pediatr. 1982;3:225

8. Phillips 5, Friedman SB, Smith J, et al. Evaluation of a residency training program in behavioral pediatrics. Pediatrics. 1983;71:406-412

9. Friedman SB, Phillips 5, Parrish JM. Current status of behavioral pedi-attic training for general pediatric residents: a study of 1 1 funded programs. Pediatrics. 1983;71 :904-908

CONGENITAL HIPS

In 1986 Drs. Klapsch, Behauner and Graf of the Stolzalpe Orthopedic Hospital

(Austria) asked the question: Is the ultrasound examination of the newborn hip

(

newborn-screening) a luxury or a necessity? They did 9870 ultrasound exams of

which 6341 were done on the post partum ward. They found 67 patients with

sonographically unstable and decentered

hip

joints. In a paper published in the

Monatsschrift der Kinderheillcunde (1991; 139:141-3) they reported 100%

success-ful treatment by ‘conservative treatment’ and thus saved future expenses and

therapy. They summarized that general, universal newborn screening-ultrasound

of the hip-was economically feasible, screening costing only 60% of a comparative

late treatment program and gave the best results and prognosis.

From: Monatsschrift der Kinderheilicunde. 1991;139:141-3. 1990;138:429-33.

Submitted Kurt Metzl, MD

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1992;90;876

Pediatrics

Esther H. Wender, Polly E. Bijur and W. Thomas Boyce