Major changes proposed for pediatric training

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oldbearprofessor

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At the bottom section are proposed very large changes in the pediatric residency requirements including a decrease in critical care/neo time, decrease in procedure requirements and different rules about subspecialties being available. What are your thoughts?

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Any insight on the impetus for these changes?

RE the decreased critical care/neo time, IN GENERAL... I tend to think that if we are going to hold fast to the idea that a general pediatrician needs 3 long years of fellowship training, then I do not have a problem with a greater proportion of residency being slanted towards general training. Someone who wants to pursue PICU or NICU training will have ample time in fellowship to gain the specialized competency (and procedure competency) that those fields require. Since the most likely outcome of these changes is to increase the amount of inpatient general peds ward time by 4 weeks... I think this further raises the question of why a PHM fellowship is really necessary to be a hospitalist. But hey, that whole thing has never made sense to me in the first place, so at this point I'm just yelling at clouds.

Removing rules about subspecialties being available seems nonideal. I'm sure it is a challenge for some smaller programs, but at least having exposure to subspecialties seems to be critical to pediatric training.
 
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I think these changes are a response to long-standing perspective that relatively few graduates practice in critical care areas. The biggest concern many have about the decreased neo/cc time and no requirement for any real procedure training is a loss of training in bag/mask ventilation and basic resuscitation skills. There are a lot of general community pedis who cover the delivery room and a lack of these skills or training may be consequential. The loss of requirement for subspecialists may lead to fewer DBP and adolescent medicine docs being hired. It will increase the number of places that can have a residency, not sure it is a great approach to training though.
 
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I think these changes are a response to long-standing perspective that relatively few graduates practice in critical care areas. The biggest concern many have about the decreased neo/cc time and no requirement for any real procedure training is a loss of training in bag/mask ventilation and basic resuscitation skills. There are a lot of general community pedis who cover the delivery room and a lack of these skills or training may be consequential. The loss of requirement for subspecialists may lead to fewer DBP and adolescent medicine docs being hired. It will increase the number of places that can have a residency, not sure it is a great approach to training though.
Your point about bag/mask ventilation and resus skills is valid, though I sort of question how durable muscle memory is after residency. It seems like if this is truly a significant part of the community practice, this is the sort of skill that really needs to be (and hopefully already is) a part of routine retraining that takes place in the practice.

I agree with you on DBP and adolescent docs. These should ideally be a required subspecialty at any center that wants a residency.
 
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Less residents in the ICU makes no difference to me, but hospitals are gonna have to higher more NPs/PAs to fill in the personnel coverage (or not till the sentinel events become too annoying to ignore).

That being said, I don't practice general pediatrics, but I get the impression that the mental health and behavioral acumen of the generalist is far more necessary than when I went through training almost 20 years ago. All the more reason for me to stay away from general peds with a 10 foot pole, but it seems like most general pediatricians need to be increasingly competent in managing anxiety, depression, autism, ADHD and the like, pharmacologically or otherwise.

Then there's the general funny contradictory statements in the review:
Residents must demonstrate knowledge of IV.B.1.c).(5).(a) the indications, contraindications, and complications for procedures; (Core)

BUT then:
The program must provide instruction and opportunities for residents to perform procedures, as applicable to each resident’s future career plans. (Core)

Must be able to demonstrate complications of a procedure... that they won't perform. I guess I get what they are saying, but still funny.

As an aside, everyone should be able to competently perform bag mask ventilation. Graduating anyone without that fundamental and life-saving skill set is a tragedy.
 
Less residents in the ICU makes no difference to me, but hospitals are gonna have to higher more NPs/PAs to fill in the personnel coverage (or not till the sentinel events become too annoying to ignore).
Yes, this is what they will do including delivery room coverage
 
Your point about bag/mask ventilation and resus skills is valid, though I sort of question how durable muscle memory is after residency. It seems like if this is truly a significant part of the community practice, this is the sort of skill that really needs to be (and hopefully already is) a part of routine retraining that takes place in the practice.
True, but hard to deliver this training effectively with real patients for attendings in most call/service systems. That's what residency is for, to develop the basic skills needed. Take that away and how will we certify people for staff privileges and ensure a basic set of experiences?
 
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Pediatric residency only needs to be a year - it is not a difficult primary care specialty
 
a loss of training in bag/mask ventilation and basic resuscitation skills.
i know its the bare minimum, but are there any hospitals that allow pediatric residents to work there without at least maintaining PALS certification? this feels like something that people are making a big deal over when in reality it will still essentially be required
 
What a complete joke. Why go to medical school anymore to become a pediatrician? Might as well become a midlevel - it would appear that the training level of the two professions will soon be the same.

No longer required: bag mask ventilation, bladder catheterization, giving immunizations, incision and drainage of abscess, lumbar puncture, endotracheal intubation, IV placement, simple laceration repair, temporary splinting of a fracture, UVC/UAC placement, chest tube placement, circumcision, thoracentesis...

Old requirements required 8-weeks EACH of both NICU and PICU . New requirements call for 12 weeks of intensive care total with only 4 weeks of NICU and 4 weeks of PICU.

You might as well forget having a pediatrician in rural areas or even smaller cities that do not have neonatologists available. It's already apparent that the recent resident graduates are hardly capable of handling neonatal resuscitation or ER codes; now you can completely forget it.

Sorry, I'm ranting. As a community pediatrician who covers a level II NICU and cares for select critical pediatric cases, I will no longer be able to recruit partners (without dumbing down our practice). Patient care and our community will suffer for it.
 
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Had a resident hold mask whilst a patient coded from a trach false track on call last night. They had never done that before. When they lost the seal, I instructed them to move their position to pull the mouth and nose into the mask and look for chest rise. Seemed like a good learning experience to me… but whatever.
 
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These are defintiely short sighted changes and will result in NP/PA replacement along with attendings who have a much narrower scope of expertise. I already see too many new attendings who are afraid of retractions instead of understanding pediatric respiratory physiology. Taking care of sick children and babies really makes you comfortable with a broad range of scenarios. Seeing premies in the nicu put me on alert for things in the regular newborn nursery and gave me much better understanding of nicu grad long term needs as they grew up. Also we have an increasing number of technology dependent children who usually go to the Picu or imc when they get admitted. They need outpatient primary care physicians who are well versed in Trach care, and at least some minimal comfort around a ventilator.

While I don’t think it’s essential for peds residents to do lines and intubations, I do think an LP is a general pediatrician’s purview, and again, familiarity with these procedures will help in follow up out patient settings.
 
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i know its the bare minimum, but are there any hospitals that allow pediatric residents to work there without at least maintaining PALS certification? this feels like something that people are making a big deal over when in reality it will still essentially be required
PALS and NRP teach the concepts, they don't even come close to teaching real world experience and skills. I've shown literally hundreds of new interns how to intubate and bag/mask on a plastic baby and that doesn't translate into being able to intubate or bag/mask ventilate the real thing.
 
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PALS and NRP teach the concepts, they don't even come close to teaching real world experience and skills. I've shown literally hundreds of new interns how to intubate and bag/mask on a plastic baby and that doesn't translate into being able to intubate or bag/mask ventilate the real thing.
agree, its definitely not the real thing at all, and I don't think removal is a good thing. I guess I just wasn't sure if the prior requirements actually required, for example, real-world BVM use to technically meet them vs. being covered by simulated training such as PALS already (that section of the guidelines didn't specify, but elsewhere "real and/or simulated training" is mentioned). I think the more worrying thing would be the loss of ICU time etc where you would expect to actually have the opportunity to actually practice/use those skills
 
You might as well forget having a pediatrician in rural areas or even smaller cities that do not have neonatologists available. It's already apparent that the recent resident graduates are hardly capable of handling neonatal resuscitation or ER codes; now you can completely forget it.

Sorry, I'm ranting. As a community pediatrician who covers a level II NICU and cares for select critical pediatric cases, I will no longer be able to recruit partners (without dumbing down our practice). Patient care and our community will suffer for it.
One of my first jobs out of residency (before I did a fellowship) was a pediatrician in a small hospital. I had to attend deliveries and help out the ED from time to time. It was pretty apparent that even as a brand new grad, I was the most qualified person in the building to take care of a kid. The EM docs have become increasingly good, especially if the kid is very sick or perfectly fine, but if it's a middle of the road kid, they often need some input. And one of my first calls was a teenager who crashed delivered 25 week twins. I had to help intubate and put umbilical lines in while we waited for neo transport to arrive. I thanked all that NICU and delivery time I had in residency that I could do that.
 
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I have a suspicion that this will lead to greater variation in the quality of pediatric graduates rather than across the board changes. The residencies that currently value graduating pediatricians who are truly competent in the removed procedures were already doing way more than required. I suspect those residencies won't change. They are already valued by residents with plans to work in more rural places where they would be called to cover deliveries and clinic and ED consults and I suspect (hope?) this will continue.

My person bias is that ICU time is valuable because pediatricians in rural areas are going to be managing these kids for a period of time and even the outpatient super-specialist in a quaternary care center is going to have kids show up to routine visits who should have been in the ED 6 hours ago and needs to get there ASAP.
 
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I swear the leadership is trying to make Pediatrics a midlevel dominated field. They are so out of touch.

Working in the ICU, learning how sick kids respond and improve and then seeing them outpatient in clinic helps immensely. Most midlevel's at my group have no idea what happens when kids are admitted.

Everyone knows PNA sounds like crackles, but actually hearing it when rounding on kids admitted for PNA + Pleural Effusions is invaluable.
 
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Pediatric residency only needs to be a year - it is not a difficult primary care specialty
Shouldnt even dignify this with a response but I will anyway. Laugh out loud ignorant
 
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This is disappointing. Working in the NICU teaches you to care for premies and working in the PICU makes you comfortable with caring for very sick children. Unfortunately, in my residency the majority of procedures were already done by midlevels and residents were only able to perform them if the mid-level declined (generally after daytime hours).

It appears like the default option for pediatric residency graduates will be outpatient pediatrics, where pediatricians will need to compete directly with a growing presence of pediatric NP's (whether their training is sufficient or not). The majority of pediatric graduates are not comfortable with running a resuscitation/code (due to no fault of their own), and this is limiting their training even further.
 
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I think the inpatient experience is what differentiates Get Peds docs from midlevels.
If anything, I would actually vote to remove most subspecialty rotations in favor of most inpatient areas, and make Hospital Med Fellowship only one year.
 
I think the inpatient experience is what differentiates Get Peds docs from midlevels.
If anything, I would actually vote to remove most subspecialty rotations in favor of most inpatient areas, and make Hospital Med Fellowship only one year.

Great for cheap labor lol
 
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