Recently Trained General Pediatricians: Perspectives on Residency Training and Scope of Practice

Abstract

OBJECTIVE. Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training.METHODS. A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4 -5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice.RESULTS. The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n ϭ 424]), sports medicine (51% [n ϭ 345]), oral health (52% [n ϭ 356]), and developmental/behavioral pediatrics (48% [n ϭ 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care.CONCLUSIONS. The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well. Pediatrics 2009;123:S38-S43 T HE SCOPE AND manner of residency training and physician decision-making regarding career choice for pediatricians was last assessed systematically in 1995 as part of the Future of Pediatric Education II (FOPE II) Project. 1 However, that project relied mostly on expert opinion and small-scale, limited research studies to assess nationally the then-current educational programs. 2 Since the FOPE II Project, there have not been significant changes in the structure of pediatrics resident education. However, the prevalence of the types of patients encountered by pediatricians today is different from at the time of the FOPE II Project. Currently, pediatricians provide care to more children with chronic illnesses than in years past. 3 In addition, new technologies have created the need for pediatricians to be aware of new genetic and other types of recently discovered illnesses and conditions. 4 Because of the increase in ...

Supply and Utilization of Pediatric Subspecialists in the United States

“…Previous work has estimated that as many as 40% of specialty visits could be managed in primary care, 40 that generalists are more willing to comanage chronic illnesses than subspecialists recognize, 41,42 and that general pediatricians with lower subspecialty access report greater comfort addressing subspecialty care needs. 43 These findings support the possibility that different generalist scope of practice due to different subspecialty supply could account for the small observed difference in utilization without adversely impacting disease burden.…”

Current state of high-risk infant follow-up care in the United States: results of a national survey of academic follow-up programs

“…5 In a recent survey of 681 general pediatricians, 1 to 5 years after completion of residency training, 48% reported that they could have benefited from additional training in developmental and behavioral pediatrics, and 18% reported need of additional training in coordination of care of complex illnesses. 6 In addition, a recent Institute of Medicine report on improving healthcare quality identified 'care coordination' and 'children with special health care needs' among the priority areas of focus in transforming the quality of healthcare. 7 Incorporating high-risk infant follow-up care training in pediatric residency curriculum may be useful in addressing these issues at least to some extent.…”

What Can Data Tell Us About the Quality and Relevance of Current Pediatric Residency Education?

“…The Freed et al survey of 7882 pediatrics residents as part of the 2007 American Board of Pediatrics in-training examination 51 sheds light on the pediatrics residency experience. In 3 other articles they examine the perspectives of pediatrics generalists 52 and subspecialists 53 within the first 2 to 5 years after certification, as well as current pediatrics subspecialty fellows 54 regarding their residency experiences and career choices. The tables display the results of additional analyses generated for this commentary: Table 1 compares the answers of generalists and subspecialists to questions about the factors considered in selecting a particular residency program and, generally, how more discretionary, flexible time in residency might be used; Table 2 compares preferences for more learning opportunities in specific content areas; and Table 3 examines the opinions of subspecialists and current fellows regarding the length of time required for residency and fellowship training.…”

“…For example, Table 1 shows that although geographic location of the residency program was the most important factor for both generalists and specialists, the importance of lifestyle issues, subspecialty expertise/training opportunities, prestige, and patient population varied. Response differences associated with gender, medical school (US or Canadian versus international), size of residency program, and subspecialty are discussed in detail by Freed et al [52][53][54] A second question raised by R 3 P Project participants was: Are current training programs flexible enough to meet training needs both for residents going into general pediatrics and those choosing subspecialty fellowship training? A careful review of the current review committee guidelines for pediatrics reveals a high degree of flexibility, with 8 to 9 months of undifferentiated time across the 33-month (allowing for 3 months of vacation) training period.…”

“…If additional flexibility had been available, most would have pursued additional outpatient subspecialty (59%) or outpatient general (41%) care. 52 Most fellows reported some flexibility during training, mainly in their choice of subspecialty electives, but desired more outpatient subspecialty (43%) and inpatient (41%) experiences. Although the proportion endorsing different settings varied between generalists and subspecialists (see Table 1), both desired more exposure to outpatient subspecialty care.…”