January 2009 Pediatrics supplement on residency and fellowship training

[oldbearprofessor]

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There is a supplement to "Pediatrics" this month (1/2009) with a number of articles about residency training in pediatrics. Feel free to comment on any aspect of these, but I wanted to note a couple of things for comments.

From the article surveying residents (Pediatrics 2009;123:S26-30) there is a table (Table 2) about postresidency plans. A very consistent 47-49% from PL-1 to PL-3 plan on fellowship. But, the number planning general pedi or hospitalist goes from 24% total (with 29% uncertain) to 43% (with 10% uncertain) between PL-1 and PL-3. In other words, accounting for some "changes" among those interested in fellowship, these numbers seem to imply that a fixed % of folks enter pedi residency having decided to do "some" fellowship. However, those who are "uncertain" will end up choosing general pedi (hospitalist is at 3% of these). This has been my experience as well from talking to PL-1's, but it is worth a discussion.

The second issue is one buried on S48 of that issue (Pediatrics 2009;123:S44-49). In this case, they surveyed subspecialists who took subspecialty boards in 2002-2006 (various groups) and asked them if they would have chosen a 2-year fellowship without research. 42% said yes. I might have predicted a bit higher, but regardless, it's a fairly substantial number.

The text with this has this quote "One potential unintended consequence of changing to a 2-year fellowship requirement would be what is now being observed in the career choices of internal medicine residency graduates. There has been a continual decline in those pursuing generalist careers over the past decade...."

Any thoughts on these or other issues brought up in the supplement?

 

[tantrum]

I read that article too. I should have finished my fellowship If I do not have to do research. I don't think it's much of a problem having more subspecialists in Pediatrics as that's where the current and future shortage is (compared to internists) and there is a projected oversupply of general pediatrician (which I don't see at the moment but MIGHT happen in 20 years).

 

[CrazyPeds527]

Although a substantial number of subspecialists say they now would have chosen a 2 year fellowship without research, those number may be biased by the jobs they have chosen. My understanding via the AAP's requiring a research project during fellowship is to prepare fellowship grads for academic jobs. Those grads that DO NOT choose academic jobs are much more likely to say they didn't need the research because it doesnt influence their day-to-day life. I wonder if those grads that will re-enter academic medicine later on and will be required by their institution to churn out some research would change their survey opinion. I wonder, as well, would the AAP change the requirements to 2 years if that would affect the number of current grads that choose not to do fellowship simply because of the length of training. However, i would counter that 2 versus 3 years, in larger scheme of life and training, is not much to do what you truly want for a living

I was a little disappointed at the rest of the supplement thinking that there were going to be some issues addressed within the context of residency training, particularly in light of the new IOM work-hour restrictions. However, it seemed the articles addressing the training didnt say much more than "We like it the way it is (grossly over-simplified)"

Thoughts from others?

 

[oldbearprofessor]

I wonder if those grads that will re-enter academic medicine later on and will be required by their institution to churn out some research would change their survey opinion.

In my experience, when folks go from private practice of a pedi specialty back into academics, their academic contribution is in education, not research, or at most clinical research in helping to run a clinical research project. Academic institutions are mostly desperate for faculty who are clinician-educators and don't expect them to do research.

The interesting question is what draw these folks back into academic faculty positions. I think it has to do with the hassle of running a practice and what I think may be a narrowing of the salary gap. Other thoughts on that?

 

[edmadison]

I've only read a few of the abstracts, but I do agree that shorter fellowships should be considered. I have a friend who definitely would have done adolescent medicine if it were shorter. Three years for adolesecent? Come on! And if you do chose that fellowship, you get rewarded with a pay cut! On the other end of the specialty spectrum, many PICU fellowship programs only have 15 months of rotations. Nothing like being a research slave for 21 months. And what about the quality of the research? Seems like many peds fellows are doing mediocre clinical research based on parent surveys and what not.

The ABP has a monopoly and there's not much we can do about it. As a consequence, some fellowships will go unfilled and others will be filled with lower quality pediatricians. Thank goodness there isn't a shortage of subspecialists -- oh wait, there is.

Ed

 

[CrazyPeds527]

Academic institutions are mostly desperate for faculty who are clinician-educators and don't expect them to do research.

The interesting question is what draw these folks back into academic faculty positions. I think it has to do with the hassle of running a practice and what I think may be a narrowing of the salary gap.

Interesting...i didnt know that about institutions looking for educators; i had seen the opposite at one of the places i did some training, where they had the educators but were looking for the basic scientist/clinicians.

Do you more experienced guys know what the ABPs thought on shorter fellowhips is, especially with some of the fields really being hammered by a workforce shortage?

 

[oldbearprofessor]

Interesting...i didnt know that about institutions looking for educators; i had seen the opposite at one of the places i did some training, where they had the educators but were looking for the basic scientist/clinicians.

Do you more experienced guys know what the ABPs thought on shorter fellowhips is, especially with some of the fields really being hammered by a workforce shortage?

Everyone wants a researcher who comes with their own funding! But, academic institutions also need folks to see patients and so they'll take on plenty of clinicians even if they don't do much or any research. This would depend a bit on the institution, but would be true of most of the big name places as they have a large clinical burden.

Although shortening fellowships by creating a clinical tract is always on the table, I'm unaware of any serious move to go in that direction.

 

[waldenwoods]

As a medical student who hasn’t yet started residency training, I found that the most interesting things were not exactly those articles on people’s opinions of residency training (separate articles for subspecialists, general pediatricians, fellows, or residents). The authors of the other articles in that supplement used that information to point out that people who practice in different settings have different needs for pediatric education, and related it to how diverse children’s health needs can be.

I didn't know that a formalized group of people set out several years ago to identify ways to improve upon the delivery of healthcare to children by changing the way we look at pediatric education. Even though it may be a while before pilot projects get started and I may never see one during my residency, I just thought it was great that this was published now (i.e., before I start residency) because it acknowledges that future changes should be made with the goal of improving care for children.

It's a lot to think about. There are so many stakeholders, and such diverse healthcare needs of children--what are the important skills you need to learn as a resident in order to be prepared to go into practice or into subspecialty fellowship?

I was a little disappointed at the rest of the supplement thinking that there were going to be some issues addressed within the context of residency training, particularly in light of the new IOM work-hour restrictions. However, it seemed the articles addressing the training didnt say much more than "We like it the way it is (grossly over-simplified)"

Thoughts from others?

Not really, I kind of thought the opposite, which was that the articles were about justifying the reccommendation to continually update pediatric education to meet the healthcare needs of children in an environment that is constantly changing.

Also, with respect to the IOM’s recommendations about work hours, I think that all of these articles were written before that report was published (about two months ago) so that’s probably why there isn’t any specific commentary on how further restricting work hours would change pediatric education.

 

[oldbearprofessor]

I was a little disappointed at the rest of the supplement thinking that there were going to be some issues addressed within the context of residency training, particularly in light of the new IOM work-hour restrictions. However, it seemed the articles addressing the training didnt say much more than "We like it the way it is (grossly over-simplified)"

This month's Journal of Pediatrics has a very strong commentary regarding the negatives of further changing work hours right now. It appears that several subspecialty organizations within the pediatric community have endorsed this commentary. It points up a range of negatives to the IOM suggestions, especially as related to training of pediatricians.

Brion et al The Journal of Pediatrics
Volume 154, Issue 5, May 2009, Pages 631-632

Sorry, I can't post it here, but most of you can get access to J Pediatr.

 

[waldenwoods]

This month's Journal of Pediatrics has a very strong commentary regarding the negatives of further changing work hours right now. It appears that several subspecialty organizations within the pediatric community have endorsed this commentary. It points up a range of negatives to the IOM suggestions, especially as related to training of pediatricians.

Brion et al The Journal of Pediatrics
Volume 154, Issue 5, May 2009, Pages 631-632

Sorry, I can't post it here, but most of you can get access to J Pediatr.

I inferred that the authors are not just cautioning against further restricting work hours compared to the status quo, but in criticizing the skill levels of residents now they were actually advocating a looser standard than what the ACGME mandates: They referenced three reports on how pediatric senior residents are now not as good at neonatal intubation (what they call a "critical skill") as compared to the time before work-hour restrictions where it was normal to expect PL-2 residents to be masters at neonatal intubations.

What does everyone think?

(Looking forward to nursery and NICU this year 🙂)

 

[oldbearprofessor]

I inferred that the authors are not just cautioning against further restricting work hours compared to the status quo, but in criticizing the skill levels of residents now they were actually advocating a looser standard than what the ACGME mandates:

I know, I was trying to downplay that...😳

 

[CrazyPeds527]

One thing that relates to neonatal intubation that is directly part of the reason why we as residents are not as good as our predecessors - we do it less frequently for the children! (OldBear...thoughts?)

Many NICU docs at my institution have commented that as recent as 5 years ago, ALL mec-aspiration babies were prophylactically intubated. That's A LOT of kids who not all are being intubated now, if avoidable. I am nearing the end of my intern year and after 4 weeks of NICU and 2 weeks of Nursery i have intubated a grand total of...
1 baby.

This is good for the children, bad for us as trainees.

Brion's article doesn't comment on this directly. HOWEVER you will not receive any arguments about the pitfalls about more restrictions for work hours. Frequently what is a gold standard of comparison to work hour restrictions imposed among pilots of airplanes. What is usually unmentioned is that comparing a plane to a human being (where disease processes are slightly different in each person and the interaction between provider and patient makes a tangible difference in care, say, when a patient is dying) is completely foolish.

There have been instances already this year that people in my program (myself included) have eschewed workhour restrictions to remain with a sick or dying patient, just to see what happens, if not to be supportive for the family. Not unique to my program at all.

If i had to guess (an educated, informal one), I would bet that upwards of 75% of residents would support this commentary, and possibly 97% of attendings. Other guesses?

 

[oldbearprofessor]

One thing that relates to neonatal intubation that is directly part of the reason why we as residents are not as good as our predecessors - we do it less frequently for the children! (OldBear...thoughts?)

There are a whole range of reason why residents have less skill and experience with neonatal intubations and lines compared to, lets say 20 years ago...

1. We do fewer lines and intubations. Not only don't we intubate most meconium stained fluid babies, but we've cut down on our use of UAC/UVCs. We also don't intubate as many preterms in the 27-30 week range as we used to - nasal CPAP rulez!

2. Residents have become a smaller part of the overall NICU team due to a range of factors, including, but not limited to the work hour rules and RRC rules limiting the number of critical care months.

This has meant that 1) more people need to learn to intubate - NNPs, RRTs and in some places, bedside nurses and 2) as NICUs are bigger and residents cover fewer of the babies, it can be harder to "find" the resident at just the right time. This shouldn't be a factor, but it is.

3. People are more cautious about giving anyone multiple attempts at tubes. Various rules exist and nurses are more sensitive to this.

4. In general, residents are less interested in getting good at these procedures. Many perceive (correctly?) that they'll never need these skills and are less aggressive about trying to obtain them.

5. In programs with fellowships, the new fellows have fewer skills so they are less likely to turn procedures over to residents or be able to train the residents.

So, on the whole, work hour limits are just a small part of the equation here, IMHO. Now, cut the work hours down mucho more, and, as I've said before, residents move even more to the role of scut managers since no one will know if the night float resident knows anything so they'll mostly be asked to do scut, rather than procedure. Just predicting. 😎

 

[BigNavyPedsGuy]

There are a whole range of reason why residents have less skill and experience with neonatal intubations and lines compared to, lets say 20 years ago...

. . . .

4. In general, residents are less interested in getting good at these procedures. Many perceive (correctly?) that they'll never need these skills and are less aggressive about trying to obtain them.

. . . .

So, on the whole, work hour limits are just a small part of the equation here, IMHO. Now, cut the work hours down mucho more, and, as I've said before, residents move even more to the role of scut managers since no one will know if the night float resident knows anything so they'll mostly be asked to do scut, rather than procedure. Just predicting. 😎

Interesting commentary. I'm at a program where every graduate is expected to go to a remote location and cover nurseries. For that reason, intubation is a major goal of our training. I was on the high end, but I did 8 neonaal intubations (not counting meconium deliveries) during my intern year. My program also has an RRC waiver to allow for more ICU (AKA NICU) time.

By the way OldBear, I go back to the NICU tomorrow for the first time in a long time and I can't shake this pit in my stomach . . .

 

[edmadison]

I go back to the NICU tomorrow for the first time in a long time and I can't shake this pit in my stomach . . .

Dead Man Walking.

Ed

 

[Stitch]

There are a whole range of reason why residents have less skill and experience with neonatal intubations and lines compared to, lets say 20 years ago...

1. We do fewer lines and intubations. Not only don't we intubate most meconium stained fluid babies, but we've cut down on our use of UAC/UVCs. We also don't intubate as many preterms in the 27-30 week range as we used to - nasal CPAP rulez!

2. Residents have become a smaller part of the overall NICU team due to a range of factors, including, but not limited to the work hour rules and RRC rules limiting the number of critical care months.

This has meant that 1) more people need to learn to intubate - NNPs, RRTs and in some places, bedside nurses and 2) as NICUs are bigger and residents cover fewer of the babies, it can be harder to "find" the resident at just the right time. This shouldn't be a factor, but it is.

3. People are more cautious about giving anyone multiple attempts at tubes. Various rules exist and nurses are more sensitive to this.

4. In general, residents are less interested in getting good at these procedures. Many perceive (correctly?) that they'll never need these skills and are less aggressive about trying to obtain them.

5. In programs with fellowships, the new fellows have fewer skills so they are less likely to turn procedures over to residents or be able to train the residents.

So, on the whole, work hour limits are just a small part of the equation here, IMHO. Now, cut the work hours down mucho more, and, as I've said before, residents move even more to the role of scut managers since no one will know if the night float resident knows anything so they'll mostly be asked to do scut, rather than procedure. Just predicting. 😎

I have to agree with you on these sentiments. My program was neo intensive so I feel pretty comfortable around it and the people we send into neo really have great skills, but that's not the case all around. Plus I had an interest in critical care and went out of my way to get lines and intubation experience. Consequently when I attend deliveries as a hospitalist I've been comfortable (as much as you can be) getting an airway and lines when that 24 weeker crash delivers. Many of my classmates who did general peds, however, specifically went with practises where they wouldn't have to do those things so they could focus on more general pedi issues.

I guess it's a trade off. I'm not nearly as comfortable doing evals for ADHD, and I can't stand managing a medical home outpatient for those complex kids. My general peds classmates do that much better than I. None of us got circumcision experience though (nor did I want it), but I don't know if other programs are doing more of that.

 

[waldenwoods]

...new IOM work-hour restrictions...

Ok I am resurrecting this thread, as there was an article published in NEJM discussing residency training in general and the IOM report, which may have implications for pediatric residency training. Below is the abstract I've copied from the Web site:

[FONT=Arial, Helvetica, sans-serif][SIZE=+2]Cost Implications of Reduced Work Hours and Workloads for Resident Physicians[/SIZE].​

[SIZE=+1]Teryl K. Nuckols, M.D., M.S.H.S., Jay Bhattacharya, M.D., Ph.D., Dianne Miller Wolman, M.G.A., Cheryl Ulmer, M.S., and José J. Escarce, M.D., Ph.D.[/SIZE]

ABSTRACT

[FONT=arial, helvetica]Background Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads. .​

[FONT=arial, helvetica]Methods We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events. .​

[FONT=arial, helvetica]Results Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0. .

[FONT=arial, helvetica]Conclusions Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high..​

 

[DarthNeurology]

The second issue is one buried on S48 of that issue (Pediatrics 2009;123:S44-49). In this case, they surveyed subspecialists who took subspecialty boards in 2002-2006 (various groups) and asked them if they would have chosen a 2-year fellowship without research. 42% said yes. I might have predicted a bit higher, but regardless, it's a fairly substantial number.

The text with this has this quote "One potential unintended consequence of changing to a 2-year fellowship requirement would be what is now being observed in the career choices of internal medicine residency graduates. There has been a continual decline in those pursuing generalist careers over the past decade...."

I think research has intrinsic value beyond just for someone who completes a fellowship and pursues a research track at an academic institution. In theory all subspecialists should be up to date with the current literature in their field and attend subspecialty conferences and so are academic to some extent. Research, I believe, teaches critical thinking skills beyond what you get in medical school and residency. Many subspecialists enjoy doing research during their fellowship although they did not move into strictly research driven careers. If you take the research out of a fellowship and shorten it to two years it is not the same thing. Sure you may get to do the same procedures and see the same type of patients, but something is lost and it is hard to quantify what that loss is.

I think a good percentage of pediatric subspecialists do go on to use their research in significant ways, be it in teaching or a clinical research project and yes, it does turn some subspecialists onto a research career. If taken out of the fellowship then the fellowships in general would be producing fellows with less research background and less inclination to do research, and perhaps in some eyes as less educated. So, I think it is a good idea to keep research components in fellowships as the benefits outweight the applicants who don't want to do any research or who have to "suffer" through a research project.