EDUCATION
GROVER F. Powns, M.D., Contributing Editor
GRADUATE
TEACHING
OF
PEDIATRICIANS
IN
A
CHILDREN’S OUTPATIENT DEPARTMENT#{176}
By BARBARA M. KORScH, M.D., D S. Z. Lvi, M.D.
New York City
171
T
lIE NEED for more outpatient experience in pediatric education is gainingrecog-nition. This trend has led to a number of attempts to incorporate pediatric outpatient
work as an integral part of undergraduate and residency training programs in various
medical centers. These efforts are as yet too
new to assess completely the value of this
reoriented kind of training.
In The New York Hospital-Cornell Medi-cal Center, Department of Pediatrics, a
fellowship training program in the Outpa-tient Department for graduate pediatri-cians-in-training has been in existence since 1942 but it has functioned in its present
form only since 1949.
A number of features, administrative, professional, clinical and physical, provide The New York Hospital Pediatric Clinic
with optimal facilities for the ambulatory care of children and the education of pedia-tricians-in-training. They include:
1. A large outpatient service comprising 30,000 to 35,000 patient visits per year. The extensive use of the clinic for con-sultations by private physicians in the community brings in many patients of unusual interest.
2. Adequate facilities for the practice of
health supervision and preventive medi-cine through the media of large well baby clinics, and health supervisory clinics for older children and adolescents.
3. An appointment system allowing ample
time for each patient visit (40 minutes for new patients, 20-30 minutes for
re-visits), and continuity of follow-up by the
same physician.
0 From The New York Hospital-Cornell
Medi-cal Center, Department of Pediatrics.
4. Privacy for patients and doctors by as-signment of a single room to each doctor for each clinic session.
5. Close professional supervision of the pediatricians-in-training. During each general clinic session a senior staff mem-ber is on call as a consultant and each specialty clinic is headed up by a quali-fled senior staff member. Moreover, there is a daily review of all clinic records by the full time chief of clinic, her assistant, or a delegated staff member.
6. The operation of a number of specialty
clinics within the Pediatric Outpatient
Department designed for research and
training. These are: Cardiac (congenital
and rheumatic) , Renal, Metabolism,
Al-lergy, Hematology, Transfusion,
Pulmo-nary, Neurology and Premature Followup Clinics. Several of these have a scheduled teaching conference for case discussion immediately following the clinic session.
7. Availability of all the paraprofessional
and ancillary services of the Center to clinic patients, and provision of separate facilities for fluoroscopy for use by the
outpatient staff.
8. The availability of a corps of consultants within the Pediatric Clinic itself. Thus when a physician-in-training (or any other staff member) wishes a consultation from
surgery, dermatology, gynecology,
psy-chiatry, or other specialties he need not refer his patient to another departmental clinic. Instead he reviews the manage-ment of the child with the consultant within the environs of the Pediatric Clinic. This arrangement obviously makes for a better learning experience for th
pediatrician and at the same time
im-proves service to patients.
172 BARBARA M. KORSCH AND S. Z. LEVINE
Clinic. These facilities not only improve the over-all care of patients, but they also
serve to familiarize the doctors with
problems and resources within the family,
school, and community.
Fellowships are granted for periods of six months to preferably 12 months without salary or room and board allowance. Some of the fellows have been able to obtain financial support from outside sources.
Each fellowship is planned in advance with consideration to individual prefer-ences. As a rule, the one-year fellowship includes a minimum attendance of three
months in each specialty clinic and assign-ments throughout the entire year to the General Pediatric and Well Baby Clinics
to allow each physician to have a con-tinuous relationship with his patients dur-ing his term of service. Assignments to the
Allergy Clinic are also made on a yearly
basis when possible to enable the
physi-cians-in-training to observe variations in the course of their patient’s symptoms during the different seasons of the year. They are
assigned regularly to the Pediatric Emer-gency and Isolation Units in the Outpatient Department.
Rotation of fellows through The New
York Hospital Nursery School provides the
opportunity to observe normal pre-school
age children in a non-medical setting. They
also participate in a number of joint enter-prises of the Pediatric and Obstetric
De-partment of The New York Hospital such
as discussion groups for expectant mothers and fathers, and discussions with mothers of normal newborns. In this way, they learn about parents’ attitudes and anxieties.
There is close integration of the Out-patient Department with the Inpatient Service both on formal and personal levels.
Rounds on inpatients are open to the out-patient staff; outpatient fellows are
en-couraged to follow their patients during
hospitalization. Besides ward rounds, a
series of teaching conferences are scheduled daily for inpatient and outpatient personnel
throughout the academic year. These podia-tic conferences include:
Cliical-Pathologi-cal Conferences, X-ray Demonstrations, Case Discussions, Follow-up Presentations, Interdepartmental Conferences, seminars
on growth and development and emotional problems in children, and therapy confer-ences. Special conferences are conducted on the ambulatory management of children with common orthopedic problems, eye
dis-orders, specific reading disabilities, and other handicapping conditions. Fellows are
given the opportunity to participate in a
course at the nearby Memorial Hospital on cancer and allied diseases in childhood. They are also encouraged to engage in clinical research projects and to present their results to other members of the staff at scheduled meetings.
Q
uestionnaires were recently sent to the35
pediatricians who have served asout-patient fellows since 1942. Of the 27 which
were returned, 22 came from all those fel-lows who were here since July 1949, when the fellowship was systematized in its pres-ent form. Some generalizations are
perti-nent:
Of the 22 more recent fellows, five served
for six months; 15 for one year; and two had their fellowships interrupted by out-side obligations. Eighteen had completed
between two and four years of graduate and post-graduate medical training, and the remaining four had even longer medical training prior to their fellowships. Ten of the 22 had had one year of hospital pedia-trics; two, 18 months; and nine, two years.
Only one fellow had had no previous spe-cial training in pediatrics and it was the consensus that the fellowship is not suit-able as an initial year of pediatric training.
Seventeen of the fellows elected the fel-lowship for training credit in preparation
for pediatric board examinations; three for practice credit; and two without credit. Seven have already taken and passed the
Board examinations. Most of the others will take the examination within the next few
years.
173
have 1)rofited more from s1)eflding the same
amount of time on an inpatient residency?” all except two, whose previous hospital
training in pediatrics had been definitely inadequate in quantity or quality, empha-sized that the fellowship training was
dif-ferent; that it should not take the place of
inpatient training in any way, but that it
did in turn offer a kind of pediatric
experi-ence that would not have been obtained from a hospital residency. They all stressed
that the fellowship was an excellent experi-ence in the later years of formal training, especially in the year of transition from the
hospital to private practice.
Another question read: “Briefly, what would you say were the outstanding con-tributions to your training that resulted
from the time you spent on the fellowship?” Fourteen of the fellows replied that the rotation through the specialty clinics had
filled an important gap in their previous training, and 12 mentioned that the Out-patient Department experience had given them a good basic training in handling the
common “minor” problems in pediatric practice for which little training is given
in the usual residencies and which
con-stitute the bulk of later practice. Eight
fel-lows commented that they had learned a good deal about the psychological aspects of pediatrics during their tenure, and eight
others remarked that they had realized for the first time during their fellowship the role of the pediatrician in the family and the technics of handling parents. The
Nursery School and Adolescent Clinic were
repeatedly mentioned as valuable media for psychological orientation. The impor-tance of the long follow-up on all patients was mentioned in four of the question-naires, and six fellows specifically reiterated
the value of this long term experience in
the Allergy Clinic. The special training in fluoroscopy was considered an asset by six fellows. General approbation was expressed for the careful supervision, the smooth con-duct of the service, the availability of con-sultants, and the generally relaxed working
atniisphere. Five fellows voluntarily stated
that their fellowship year was the best year of their entire training period.
The response to the query: “What would you say were the main defects of the train-ing you received as a fellow here?” centered around three areas. One related to
made-quate training in the area of common pediatric orthopedic problems. This year a special session of the Orthopedic Clinic is
being operated in the Pediatric Outpatient Department, so as to teach medical students and pediatricians-in-training some aspects
of orthopedic problems in childhood, with special emphasis on rehabilitation. The sec-ond referred to insufficient training in the
field of pediatric dermatology. This defect has been corrected by providing more ex-tensive dermatology consultations in the
Pediatric Department. Althought so many
of the fellows in their comments single out the fact that the fellowship gave them the
opportunity to learn more of the
psycho-logical aspects of pediatrics than had been offered in their total previous pediatric ex-perience, a third group still felt that there
should have been closer cooperation with the Department of Child Psychiatry, better
facilities for diagnosis and treatment of
emotional problems, and more specific teaching of growth, development and be-havior problems.
This area of pediatrics is generally recog-nized as being the most problematic from the point of view of service and teaching. It will probably be a long time before the needs for this kind of teaching are filled or even properly understood. Technics are
being developed in different medical cen-ters to attempt to fill these needs. The De-partment of Pediatrics at The New York
Hospital-Cornell Medical Center estab-lished an Institute of Child Development
in 1943 under the direction of Dr. Milton
J.
E. Senn. Different approaches have been tried to teach this subject and currently plans are in progress for setting up more174 BARBARA M. KORSCH AND S. Z. LEVINE
1)are1ts, I)arellts of newborns, and other parents, assignments in the Well Baby Clinic, Nursery School, and Occupational
Therapy, and teaching of growth and de-velopment, emotional as well as physical, are being expanded. Even at present, a
considerable portion of the pediatric teach-ing program is aimed at the teaching of
psychological aspects of pediatrics, but
ap-parently the pediatricians-in-training are conscious of an increasing need for
teach-ing and service in these aspects of pedi-atrics.
It was pointed out by the former fellows that experience in home care would be a valuable adjunct to the fellowship training.
A limited home care program is in operation at The New York Hospital-Cornell Medical
Center as part of the Comprehensive Care and Teaching Program of the Medical
Col-lege; however, only a few of the fellows
have participated in this portion of the
service so far.
It is of interest that a few of the former fellows suggested that it might be desirable
to incorporate this fellowship training into
a two year residency program which would
be divided between inpatient work giving a great deal more time to the Outpatient
Department than do current residencies.
SUMMARY
A brief description is given of an out-patient fellowship program for
pediatricians-in-training which has been in operation at
The New York Hospital-Cornell Medical Center since 1942.
The reaction of the participating fellows,
