Advancing Medical Education Training in Adolescent Health

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COMMENTARY

Advancing Medical Education Training in Adolescent

Health

Harriette B. Fox, MSSa, Margaret A. McManus, MHSa, Angela Diaz, MD, MPHb, Arthur B. Elster, MDc, Marianne E. Felice, MDd,

David W. Kaplan, MD, MPHe, Jonathan D. Klein, MD, MPHf, Jane E. Wilson, MDa

aIncenter Strategies, Washington, DC;bMount Sinai Adolescent Health Center, New York, New York;cAmerican Medical Association, Chicago, Illinois;dUniversity of

Massachusetts Memorial Children’s Medical Center, Worcester, Massachusetts;eUniversity of Colorado School of Medicine, Denver, Colorado;fUniversity of Rochester

School of Medicine, Rochester, New York

The authors have indicated that they have no financial, relationships relevant to this article to disclose.

P

ROVIDING COMPREHENSIVE CARE to adolescents is a

multifaceted undertaking, requiring not only rou-tine medical services but also health education, risk reduction, mental health, behavioral health, and sex-ual health services. Yet, this vital spectrum of care is unavailable to most adolescents. Not only is there a paucity of adolescent medical specialists, but many pediatricians—the providers increasingly likely to care for adolescents—report that they lack training and confidence in diagnosing and managing adolescents’ psychosocial and reproductive problems.

Although this issue has not been the subject of much research, 1 national survey of pediatricians in 1998 found that 57% cited lack of training in gynecological care and 40% reported lack of training in mental health as significant barriers to providing needed services to adolescents.1Incenter Strategies’ recent national surveys

of adolescent medicine fellowship program directors, pe-diatric residency program directors, and adolescent med-icine faculty in pediatric residency programs show a high degree of support for new options to enhance clinical training in adolescent medicine. The response rates, ranging from 75% to 88%, underscore the salience of this issue for academicians.

Currently, pediatric residency programs, like other primary care residency programs, are not structured to give in-depth attention to adolescent medicine. The re-quired rotation for adolescent medicine is just 1 month, with that time allotment exceeded by only 5% of resi-dency programs.

During the rotation, residents receive at least some training on a wide variety of adolescent health issues. Yet, in our survey, a third or more of adolescent medi-cine faculty responsible for the one-month rotation re-port that, in terms of clinical practice and application, exposure to key adolescent medicine topics is limited. Faculty report that areas such as anticipatory guidance, health promotion, disease prevention, chronic illness, mental health and behavioral health are only somewhat covered or not covered at all.

Residents generally train in a small proportion of the settings in which adolescents typically receive care, ac-cording to surveyed faculty. Moreover, time spent in each site is often limited to a few days. In the predom-inant clinical site where residents are trained, adolescent medicine faculty report that mental health, behavioral health, and sexual health services are not consistently

available. Neither are needed specialists; in fact, a psy-chiatrist or obstetrician/gynecologist is regularly on staff at only⬃10% of these clinics.

Although clinical training in adolescent medicine should be integrated throughout residency training, most residents’ exposure to adolescents is currently fo-cused heavily on inpatient and subspecialty care in which the medical concerns of the general adolescent population are not the focus of training. Continuity clin-ics might be expected to provide balance by offering opportunities for wide-ranging clinical experience in ad-olescent medicine. Yet, pediatric residency program di-rectors, in more than a third of programs report that adolescents comprise 10% or less of the pediatric patient population in continuity clinics. Moreover, in well over three-quarters of programs, residents rarely see the same adolescent patient more than once in continuity clinic settings.

Given these findings, it seems that the time has come to consider the need for major reforms in adolescent medicine training. At least 4 reform options should be examined: 1) extending the length of the mandatory adolescent medicine rotation, 2) introducing more flex-ibility in residency programs to allow for formalized optional training tracks in adolescent medicine 3) creat-ing a combined pediatrics/adolescent medicine resi-dency, and 4) increasing the availability of one-year adolescent medicine clinical training programs after completion of categorical training in general pediatrics. Each option has distinct strengths and weaknesses.

Requiring a longer adolescent medicine rotation of-fers the advantages of encounters with more adolescents and a broader array of problems, more time spent at community sites, and increased exposure to faculty with expertise in adolescent medicine. Extending the length of the rotation, however, would not necessarily address the need for more experience developing longitudinal therapeutic relationships with adolescents, arguably a

Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

www.pediatrics.org/cgi/doi/10.1542/peds.2007-3720

doi:10.1542/peds.2007-3720

Accepted for publication Jan 22, 2008

Address correspondence to Harriette Fox, MSS, CEO, Incenter Strategies, 750 17th St, NW, Suite 1100, Washington, DC 20006. E-mail: hfox@incenterstrategies.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2008 by the American Academy of Pediatrics

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more important goal for training in adolescent medicine. Residency programs would have to require longitudinal clinical competencies specific to adolescent medicine. Nor would lengthening the rotation expand opportuni-ties to receive training from child and adolescent psychi-atrists or obstetrician/gynecologists, if they are not al-ready part of the adolescent medicine training.

A second option is to introduce more flexibility into pediatric residency programs primarily by loosening ACGME and ABP requirements. This could be an effec-tive way to match residents’ long-term career interests with training needs, both in adolescent medicine and in other areas. Currently, opportunities for elective rota-tions vary across training institurota-tions but generally are fairly limited, averaging ⬃6 electives at most institu-tions. Although residents now only rarely select a second rotation in adolescent medicine, the adoption of formal-ized optional training tracks could encourage residents planning career paths in primary care to consider ado-lescent medicine as a special area of practice.

Additional flexibility could give trainees interested in caring for adolescents the opportunity to spend more longitudinal and focused rotation times in adolescent medicine clinical settings and with faculty who have expertise in this area. Trainees might also be able to do rotations in related specialties, such as child and adoles-cent psychiatry and in obstetrics/gynecology. Some teaching hospitals, however, might hesitate to introduce such flexibility if it conflicted with other staffing needs. Furthermore, meaningful opportunities for flexibility would probably reduce time spent in some areas that are currently required.

A third option, creating a combined or “integrated” pediatrics/adolescent medicine residency program, would produce pediatricians with expert skill in both general pediatrics and adolescent medicine. This alter-native is consistent with the growth of interest in com-bined pediatric residencies, although the 6 currently of-fered combine pediatrics with other medical specialties, not with a pediatric subspecialty.

Combined training would offer significantly more ex-posure to adolescent patients, a variety of training sites and experiences, and expert faculty. It would also allow for a shorter pathway to dual certification (based on clinical-only training in adolescent medicine). However, it may be difficult to recruit enough faculty for combined programs, particularly in mental health. Competition with other training programs for faculty and training sites, already a problem, would only be exacerbated.

The fourth option, to expand the availability of one-year clinical training programs postresidency, would have the least impact on the current pediatric residency structure. Training could be offered, as it is now, through existing adolescent medicine fellowship programs or through clinical practices with sufficient resources.

This option, which was more widely available before the adoption of the 3-year requirement for adolescent medicine subspecialty certification, would allow pedia-tricians who are primarily interested in the clinical prac-tice of adolescent medicine to gain additional proficiency in clinical skills. However, trainees completing a

one-year program would currently be ineligible for board certification in adolescent medicine. Unless the ABP was able offer subspecialty certification in clinical care after 1 year of training—as has been done in geriatric medicine—some residents may be unwilling to com-plete an extra year of training.

Among physicians in academic medicine—adolescent medicine fellowship program directors, pediatric resi-dency program directors, and adolescent medicine fac-ulty in pediatric residency programs—there seems to be considerable interest in enhancing training experiences in adolescent medicine. Our recent national surveys sought the perspectives of each of these academic groups regarding support for 3 new training options: extending the length of the adolescent medicine rotation, creating a combined residency program, and increasing the avail-ability of one-year clinical training programs. (They were not asked about increasing flexibility in residency training.)

Our findings show that adolescent medicine fellow-ship program directors are supportive of change, with just over half endorsing each option. Nearly all fellow-ship program directors favor at least 1 of the reform options presented; almost a quarter endorse all 3 op-tions. Perhaps most noteworthy is the high level of support for creating a combined residency program and for one-year training programs, given the potential im-pact of each of these options on fellowship training.

However, it is somewhat surprising that more fellow-ship program directors did not support a longer block rotation. Perhaps they anticipated that additional re-quirements would meet substantial resistance, or that an extension of the block rotation would fail to produce sufficient improvements in adolescent medicine compe-tencies.

Survey responses of pediatric residency program direc-tors similarly indicate support for new training options. In fact, three quarters of residency program directors support increasing the availability of one-year training programs. Compared with the other surveyed groups, however, program directors are far less interested in the other 2 options, with fewer than 10% of program directors fa-voring either an extended block rotation or a combined residency program.

Presumably, program directors would have been more amenable to changes in residency requirements that allow for more flexibility in training, thereby per-mitting interested residents to spend more time in ado-lescent medicine settings. Pediatric residency programs are already challenged to provide a balanced coverage of the wide range of topics and subspecialties that are re-quired of them and increasing the length of the adoles-cent medicine rotation would require decreasing train-ing in another area.

Adolescent medicine faculty responsible for the one-month rotation expressed considerable support for change as well. Like the residency program directors, almost 75% of surveyed faculty support increasing the availability of one-year programs, the option that has the least impact on residency programs and is most targeted to those residents who desire additional clinical training.

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However, unlike residency program directors, faculty who run rotations are more supportive of the other 2 options, with more than half favoring a longer rotation and nearly 30% supporting a combined residency pro-gram.

Training pediatricians to provide comprehensive care to adolescents is a complex challenge, one that has spurred much discussion but little sustained effort to-ward meaningful reform. Clearly, the need for change extends beyond the field of pediatrics: family medicine, which provides 40% of health care to adolescents,2

war-rants training reform as does internal medicine, obstet-rics/gynecology, and psychiatry, which often assume care for older adolescents and young adults. Nonethe-less, given pediatricians’ particular expertise in the de-velopment, disorders and needs of young people, the specialty is well positioned to lead an effort to improve services to our nation’s adolescents. Training programs might begin now by requiring 2 rotations in adolescent medicine and additional continuity clinic opportunities with adolescents at least on a monthly basis. These are not major reforms but are improvements that could be adopted without ACGME or ABP action.

As we consider ways and means to better prepare physicians to meet adolescents’ health care needs, the training options discussed here may prove useful. We need to more precisely identify the distinctive compe-tencies needed by physicians who care for adolescents. What is the necessary skill set for all pediatricians treat-ing adolescents, compared with that required for special-ists in the clinical practice of adolescent medicine, and for those pursuing a career in academic medicine?

Regarding clinical practice, research points to signifi-cant disparities between the skills obtained during resi-dency and the dilemmas actually faced by clinicians treating adolescents. Recent studies show that a signifi-cant proportion of pediatricians believe they lack the skills to adequately address adolescent depression and anxiety,3suicide risk,4family and peer violence,5alcohol

use,6 smoking cessation,7 and pregnancy prevention,8

with many clinicians expressing interest in additional training in these areas.

Clearly, a powerful match exists between the per-ceived training needs of clinicians who treat adolescents and the needs of adolescents for comprehensive, high-quality, accessible care. Directing our energies toward new models of adolescent medicine training is a vital step toward providing this largely vulnerable, under-served population with a healthier future.

ACKNOWLEDGMENTS

Support for the survey research included in this com-mentary came from individual and family foundation donations made to Incenter Strategies, a new nonprofit organization to promote improvements in adolescent health.

REFERENCES

1. Emans SJ, Bravender E, Knight J, et al. Adolescent medicine training in pediatric residency programs: are we doing a good job?Pediatrics.1998;102(3):588 –595

2. Freed GL, Nahra TA, Wheeler JRC. Which physicians are pro-viding health care to America’s children? Trends and changes during the past 20 years.Arch Pediatr Adolesc Med.2004;158(1): 22–26

3. Williams J, Klinepeter K, Palmes G, Pulley, Foy JM. Diagnosis and treatment of behavioral health disorders in pediatric prac-tice.Pediatrics.2004;114(3):601– 606

4. Frankenfield DL, Keyl PM, Gielen A, Wissow LS, Werthamer L, Baker SP. Adolescent patients— healthy or hurting? Missed op-portunities to screen for suicide risk in the primary care setting.

Arch Pediatr Adolesc Med.2000;154(2):162–168

5. Borowsky IW, Ireland M. National survey of pediatricians’ vio-lence prevention counseling. Arch Pediatr Adolesc Med. 1999; 153(11):1170 –1176

6. Millstein SG, Marcell SG. Screening and counseling for adoles-cent alcohol use among primary care physicians in the United States.Pediatrics.2003;111(1):114 –122

7. Kaplan DP, Perez-Stable EJ, Fuentes-Afflick E, Gildengorin V, Millstein S, Juarez-Reyes M. Smoking cessation counseling with young patients: the practices of family physicians and pediatri-cians.Arch Pediatr Adolesc Med.2004;158(1):83–90

8. Hellerstedt WL, Smith AE, Shew ML, Resnick MD. Perceived knowledge and training needs in adolescent pregnancy prevention: results from a multidisciplinary survey.Arch Pediatr Adoles Med.2000;154(7):679 – 684

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DOI: 10.1542/peds.2007-3720

2008;121;1043

Pediatrics

Felice, David W. Kaplan, Jonathan D. Klein and Jane E. Wilson

Harriette B. Fox, Margaret A. McManus, Angela Diaz, Arthur B. Elster, Marianne E.

Advancing Medical Education Training in Adolescent Health

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DOI: 10.1542/peds.2007-3720

2008;121;1043

Pediatrics

Felice, David W. Kaplan, Jonathan D. Klein and Jane E. Wilson

Harriette B. Fox, Margaret A. McManus, Angela Diaz, Arthur B. Elster, Marianne E.

Advancing Medical Education Training in Adolescent Health

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