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Training family medicine residents to care for children: What is the best approach?

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This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

Can Fam Physician 2011;57:e46-50

Abstract

Problem addressed There is a lack of consensus around the optimal way to train family medicine residents to care for children.

Objective of program Evaluation of an ambulatory versus an inpatient pediatrics rotation for family medicine residents.

Program description A 4-week pediatrics rotation for second-year family medicine residents was introduced involving half-day ambulatory pediatric clinics. A nonequivalent control

group evaluation study design was followed. Patient logbook entries, as well as residents’ satisfaction, knowledge, and self-reported confidence outcomes were compared between family medicine residents completing the new ambulatory rotation and those completing a traditional inpatient- ambulatory pediatrics rotation.

Conclusion An ambulatory rotation in pediatrics is a feasible option for facilitating family medicine resident learning in child health care.

Residents report exposure to more patient cases that reflect a family practice office setting and the same level of knowledge and confidence as residents completing an inpatient-ambulatory rotation. Intraprofessional collaboration, flexibility in scheduling, and the support of pediatric preceptors are key factors in the organization and implementation of an ambulatory rotation.

Résumé

Problème à l’étude Il n’y a pas de véritable consensus sur la meilleure façon de former les résidents en médecine familiale relativement aux soins aux enfants.

Objectif du programme Évaluation d’un stage en pédiatrie en clinique externe versus à l’hôpital pour les résidents en médecine familiale.

Description du programme Un stage de 4 semaines en pédiatrie comprenant des demi-journées en clinique externe de pédiatrie a été instauré pour les résidents de deuxième année de médecine familiale. On a utilisé un devis expérimental de type évaluation avec groupe témoin non équivalent. On a comparé les inscriptions de patients dans les registres ainsi que les issues en terme de satisfaction, de connaissances et de confiance exprimées par les résidents qui terminaient le nouveau stage en milieu externe par rapport à ceux qui terminaient le stage traditionnel en pédiatrie combinant milieux hospitalier et externe.

Conclusion Il est possible d’offrir aux résidents en médecine familiale un stage extra-hospitalier en pédiatrie pour faciliter leur apprentissage des soins aux enfants. Les résidents ont déclaré avoir été exposés à plus de cas correspondant à un contexte de pratique familiale et ont rapporté un même niveau de connaissances et de confiance que ceux qui avaient fait

Training family medicine residents to care for children

What is the best approach?

Pauline Duke

MD CCFP FCFP

Vernon Curran

PhD MEd Dip Ad Ed

Ann Hollett

MA

editor’s Key Points

• An ambulatory clinic-based rotation in pediatrics is a feasible option to facilitate family medicine residents’ learning in child health care.

• Family medicine residents who participat- ed in a child health ambulatory rotation re- ported exposure to more patient cases that reflected family practice office settings, and they recorded knowledge and confidence outcomes comparable to residents who completed inpatient-ambulatory rotations.

• Support of pediatric preceptors is essential in the development and implementation of an ambulatory clinic-based rotation in pediatrics for family medicine residents.

Points de rePère du rédacteur

• Il est possible d’offrir aux résidents en médecine familiale un stage en pédiatrie dans une clinique externe pour faciliter leur formation dans le domaine des soins aux enfants.

• Les résidents qui ont participé à un stage en pédiatrie en clinique externe ont déclaré avoir été exposés à plus de cas correspon- dant à la pratique familiale et ont rapporté des résultats comparables à ceux des rési- dents qui avaient fait des stages hospitaliers, en termes de connaissance et de confiance.

• Il faut l’appui de précepteurs en pédiatrie pour développer et instaurer un stage de pé- diatrie en milieux hospitalier et clinique pour les résidents en médecine familiale.

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leur stage en milieu hospitalier-externe. Collaboration interprofessionnelle, flexibilité des horaires et

participation de moniteurs en pédiatrie sont les facteurs clés de l’organisation et de la mise en place d’un stage en milieu extra-hospitalier.

C

hildren constitute a large proportion of a family physician’s patient population.1,2 As a key member of the primary health care team, the family phys- ician is able to assess and intervene early in develop- mental problems that could have serious lifelong health implications. The College of Family Physicians of Canada’s (CFPC’s) Task Force on Child Health2 reported that family physicians were uniquely positioned to par- ticipate in and coordinate complete health care for children. Pediatric training experiences are extremely important in preparing family physicians for future practice.3 According to the CFPC accreditation criteria, residents must be exposed to clinical settings with an adequate volume of office visits by children and adoles- cents to learn the diagnosis and management of com- mon pediatric and adolescent problems that present in the family practice setting.4 International curriculum guidelines for the care of children have also been pub- lished in the United States and the United Kingdom with similar recommendations.5,6

In a key report, Barer and Stoddart7 noted the import- ance of immersing residents in appropriate clinical set- tings, so they can gain optimal exposure to the type of patients they might encounter in future practice. Poole et al8 reported that family practice residencies needed a competency-based curriculum derived from actual pedi- atric experience in family practice. Pediatric training for family medicine residents should include attention to newborn care, neonatology, well-baby care, infectious disease, allergy, immunology, behavioural problems, learning disabilities, childhood illness, and adolescent care.8 More recently, it has been suggested that curricu- lums should focus on recognition of the sick child, acute and chronic organic illnesses, and structured adolescent health experiences.9,10 Respondents to a CFPC survey on child health care reported that family physicians should be knowledgeable about common and acute childhood problems, as well as learning disabilities, and be prepared to deal with the effects of family violence, addictions, family conflict, and separation or divorce on children.2

Melville and colleagues9 state that there is con- troversy about the most effective way to train family physicians for the pediatric challenges they will face in practice, in particular what should be included in training, what should be left out, and how long it should last. In the United Kingdom, as well as in Canada and the United States, pediatric training has been largely inpatient hospital-based. For example, some studies have found that excessive exposure to

neonatology, particularly neonatal intensive care, was perceived as generally irrelevant for family practice trainees.9 Declining hospitalization rates for children and an increased emphasis on ambulatory care are affecting the way family practice residency programs train their residents in the care of children.3 In a US study, Baldor and Luckmann3 found that residencies required a mean of 5.2 months of formal pediatric training and more than 89% required some structured pediatric outpatient training, while a small number of programs combined an outpatient experience with the inpatient pediatrics rotation.

The CFPC Task Force on Child Health identified inad- equate exposure to a range of common and important child health problems in postgraduate medical educa- tion programs as a weakness at most Canadian univer- sities.2 Suggestions to improve postgraduate education included ensuring adequate exposure to common child- hood illnesses and well-child care.2

The family medicine residency program at Memorial University of Newfoundland introduced a new ambula- tory pediatrics rotation in 2004 at the Janeway Children’s Health and Rehabilitation Centre in St John’s, Nfld, to enhance family medicine residents’ learning experiences in pediatrics and adolescent health care. Traditionally, the family medicine pediatrics rotation at this hospi- tal was based on inpatient learning experiences. The revised curriculum structure was developed to provide family medicine residents with a more effective experi- ence learning about the diagnosis and management of common pediatric and adolescent problems that present in the family practice setting.

Description of program

The 4-week ambulatory pediatrics rotation for second- year family medicine residents was based on a series of clinical learning experiences in ambulatory clinical settings. The family medicine pediatric faculty coordin- ator, the chair of the discipline of pediatrics, pediatricians, pediatric subspecialists, and surgeons were instrumental in the planning and implementation of the new curricu- lum. There was no inpatient call during the rotation, and residents attended a total of 9 pediatric clinics per week.

An individualized month-long schedule was arranged on a monthly basis; this ensured maximum learning with low learner-to-preceptor ratios. Only second-year resi- dents were involved in this rotation and therefore had broader clinical experience to call on. Participation in the clinics was mandatory and family medicine residents were supervised by the attending pediatrician or pediat- ric surgeon. Residents were also able to attend a visit- ing consultant pediatric clinic for a full day in a nearby rural area. Attendance at pediatric teaching rounds was encouraged and attendance at family medicine aca- demic half-days every week was expected. Resident

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performance was assessed by each supervising phys- ician at the end of each clinic by verbal and written feed- back on “pediatric evaluation cards.” Residents were also required to maintain patient logbooks to demonstrate the range of patients and problems encountered during their rotations. Residents who did not complete the require- ments satisfactorily had to complete remediation.

An evaluation research study was undertaken to compare the effectiveness of the new ambulatory pedi- atrics rotation with a traditional combined inpatient- ambulatory pediatrics rotation. A nonequivalent control group study design was followed. All second-year family medicine residents participating in the new ambulatory pediatrics rotation and the combined inpatient-ambula- tory pediatrics rotations at 2 other hospitals were invited to participate. Immediately before and after completion of their respective pediatrics rotations, residents were asked to complete identical pretests and posttests, assessing knowledge and confidence in the management of com- mon pediatric and adolescent problems. The knowledge assessment comprised 29 multiple-choice questions, while the confidence assessment included 22 positively worded confidence statements that residents were asked to rate using a 5-point Likert scale (1 = low confidence to 5 = high confidence). Both study groups, upon completion of their pediatrics rotations, were also required to complete resi- dent evaluation surveys. Evaluation data were collected between the 2005 and 2009 academic years.

Evaluation of program

A total of 79 residents participated in the pediatric rota- tions. Table 1 summarizes the response rates for the various evaluation instruments, which ranged from 43.0%

for the confidence posttest to 100.0% for the logbooks.

Figure 1 summarizes the various clinics attended by resi- dents for the ambulatory and the combined inpatient- ambulatory rotations. A larger percentage of residents in the ambulatory rotation reported attending a greater vari- ety of subspecialty clinics in urology; surgery; respirology;

plastics; orthopedics; ears, nose, throat; dermatology;

and allergy. Residents in the ambulatory rotation also reported attending a higher number of outpatient clinics (Table 2) and seeing a higher mean number of patients than residents participating in the inpatient-ambulatory rotation (108.3 vs 71.0 patients per resident).

Urology Surgery Respirology Plastics Orthopedics Ophthalmology General pediatricians ENT Diabetes Development Dermatology CP or spina bifida Cardiology Behavioural Asthma Allergy ADHD

Psychology

Number of births

0

Inpatient-ambulatory Ambulatory

Figure 1. Percentage of residents who attended subspecialty clinics, by subspecialty

RESIDENTS, %

SUBSPECIALTY

20 40 60 80 100

27.8

4.2 38.9

0 16.7

22.2 61.1

11.1 77.8

83.3

50

44.4 45.8

11.1 22.2

5.6 11.1 12.5

8.3 5.6

22.2 27.8

16.7 8.3

4.2 4.2

0 0 0 4.2 4.2 0 4.2 0 0 0

ADHD—attention deficit hyperactivity disorder, CP—cerebral palsy, ENT—ears, nose, throat.

table 1. Response rates for various evaluation instruments: N = 79.

INSTRUMENT N (%)

Satisfaction survey 47 (59.5)

Confidence pretest 61 (77.2)

Confidence posttest 34 (43.0)

Knowledge pretest 61 (77.2)

Knowledge posttest 36 (45.6)

Logbooks 79 (100.0)

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Table 3 summarizes a comparison of residents’

satisfaction with the ambulatory and inpatient-ambu- latory pediatric rotations. A t test analysis revealed no significant differences across most of the satisfac- tion items. Residents in the ambulatory rotation did report a significantly higher mean level of satisfac- tion with the length of the rotation than residents in the inpatient-ambulatory rotation did (P < .031).

Tables 4 and 5 summarize results of t test analysis of knowledge and confidence scores before and after ambulatory or inpatient-ambulatory rotations. Residents in the ambulatory rotation reported a significant increase in knowledge scores after the rotation (P < .001), while those in the inpatient-ambulatory rotation reported no significant increase. There was no significant difference between ambulatory and inpatient-ambulatory groups

in knowledge scores before (P = .404, t = 0.845, degrees of freedom [df] = 33) or after (P = .185, t = -1.354, df = 33) the rotations. There were significant increases in the con- fidence scores of residents in both the ambulatory and inpatient-ambulatory groups (P < .001) after the rota- tions. There was no significant difference between ambu- latory and inpatient-ambulatory groups in confidence scores before (P = .413, t = -0.830, df = 30) or after (P = .106, t = -1.665, df = 30) the rotations.

Discussion

The ambulatory rotation in pediatrics was developed to provide family medicine residents with a more effect- ive experience learning about the diagnosis and man- agement of common pediatric and adolescent problems that present in the family practice setting. The trad- itional inpatient pediatrics rotation offers family medi- cine residents exposure to a subset of patients who often require subspecialty care. There seemed to be a disconnect between what family medicine residents experienced and encountered with patients in an inpatient setting and what they would encounter in the family practice setting. The new ambulatory clinic-based rotation offered the organizing family medicine faculty

table 2. Number of outpatient clinics attended by study groups: P < .001 by χ

2

analysis.

NO. OF CLINICS ATTENDED INPATIENT-AMBULATORY GROUP AMBULATORY GROUP

≤ 20 14 (63.6) 0

> 20 8 (36.4) 15 (100.0)

table 3. Residents’ satisfaction with the rotations: Each item was scored on a 5-point Likert scale, from 1 = strongly disagree to 5 = strongly agree.

INPATIENT-AMBULATORY GROUP AMBULATORY GROUP

ITEM N MEAN (SD) N MEAN (SD) T TEST

DEGREES OF

FREEDOM P VALUE

I was given an appropriate orientation to

this rotation 25 4.60 (0.645) 16 4.44 (0.629) .794 39 .432

Main learning objectives were clearly

described and followed 25 4.32 (0.690) 16 4.31 (0.602) .036 39 .972

The clinical experience allowed for the

learning objectives to be met 25 4.36 (0.907) 16 4.44 (0.629) -.298 39 .767

A variety of patient problems

representative of the discipline were seen 25 4.36 (0.995) 16 4.56 (0.629) -.725 39 .473 The rotation was well organized with

efficient use of time 25 4.04 (0.978) 16 4.25 (0.931) -.683 39 .499

There were sufficient opportunities to participate in patient care and

management 25 4.32 (0.900) 15 4.53 (0.640) -.803 38 .427

The length of the rotation was

appropriate 25 4.00 (0.957) 16 4.62 (0.719) -2.235 39 .031

I was given support and positive

reinforcement 25 4.68 (0.557) 16 4.69 (0.704) -.038 39 .970

I was given support by nursing and

ancillary staff 25 4.60 (0.645) 16 4.56 (0.727) .173 39 .864

Textbooks, literature resources, and reading assignments were recommended to me

26 4.28 (0.737) 15 4.33 (0.976) -.196 38 .846

This rotation was educationally beneficial 25 4.48 (0.770) 16 4.69 (0.793) -.832 39 .411 Considering all aspects of this rotation,

how would you rate its overall

effectiveness? 25 4.28 (0.843) 16 4.44 (0.629) -.641 39 .525

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the opportunity to select both general and subspecialty pediatric clinics that would be most beneficial to family medicine residents. The cooperation of the pediatric pre- ceptors and the familiarity of the faculty facilitated organ- ization of the rotation. The key findings of the evaluation study indicated that residents in the new ambulatory rotation performed as well on knowledge and con- fidence outcomes, and reported the same satisfaction levels, as residents participating in traditional inpatient- ambulatory rotations. Residents in the ambulatory rota- tion did report a significantly higher mean level of satis- faction in the length of the rotation (P < .031).

In a previous study, Melville et al9 found that fam- ily physician satisfaction with training in pediatrics was directly related to its duration, with low levels of satis- faction with training of shorter duration. It is possible that the higher satisfaction rating recorded in the cur- rent study might be reflective of the broader clinic expe- riences to which residents were exposed and the higher number of patients seen. Assessment of resident perfor- mance was more cumbersome in the ambulatory rota- tion, as residents were supervised by many supervisors, whereas in the traditional inpatient-ambulatory rotation only 1 or 2 preceptors might be involved.

Conclusion

An ambulatory rotation in pediatrics is a feasible option for facilitating family medicine resident learning in child health care. Residents participating in an ambulatory rotation reported greater satisfaction with the length of the rotation and exposure to more patient cases that reflect a family practice office setting, and they recorded the same level of knowledge and confidence outcomes compared with residents completing an inpatient- ambulatory rotation. Intraprofessional collabora- tion between the disciplines of family medicine and

pediatrics, flexibility in scheduling, and the support of pediatric preceptors are key factors in the organization and implementation of an ambulatory rotation.

Dr Duke is Associate Professor in the Department of Family Medicine; Dr Curran is Professor of Medical Education at the Centre for Collaborative Health Professional Education in the Faculty of Medicine; and Ms Hollett is a research coordinator at the Centre for Collaborative Health Professional Education, all at Memorial University of Newfoundland in St John’s.

Contributors

Drs Duke and Curran were co-principal investigators of the research study.

Dr Duke, Dr Curran, and Ms Hollett made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published.

Competing interests None declared Correspondence

Dr Pauline Duke, Health Sciences Centre, Memorial University of Newfoundland, St John’s, NL A1B 3V6; telephone 709 777-6743; fax 709 777-7913; e-mail pduke@mun.ca

references

1. Walker V, Wall DW, Goodyear HM. Paediatric training for GP VTS trainees: are we meeting the requirement? Educ Prim Care 2009;20(1):28-33.

2. College of Family Physicians of Canada Task Force on Child Health. Our strength for tomorrow: valuing our children. Part 6: educating family physicians to care for chil- dren. Can Fam Physician 1998;44:119-28.

3. Baldor RA, Luckmann R. A survey of formal training in the care of children in family practice residency programs. Fam Med 1992;24(6):426-30.

4. College of Family Physicians of Canada. Standards for accreditation of residency training programs. Mississauga, ON: College of Family Physicians of Canada; 2006.

Available from: www.cfpc.ca/uploadedFiles/Education/Red%20Book%20 Sept.%202006%20English.pdf. Accessed 2010 Dec 8.

5. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents adolescent health. Leawood, KS: American Academy of Family Physicians; 2008. Available from: www.aafp.org/online/ etc/medialib/

aafp_org/documents/about/rap/curriculum/adolescent_health.Par.0001.File.

tmp/Reprint278.pdf. Accessed 2010 Dec 8.

6. Royal College of General Practitioners. Royal College of General Practitioners cur- riculum statement 8. Care of children and young people. London, Engl: RCGP; 2007.

Available from: www.rcgp-curriculum.org.uk/pdf/curr_8_Care_of_Children_and_

Young_People.pdf. Access 2010 Dec 8.

7. Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada. Report prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health.

Ottawa, ON: Government of Canada; 1991.

8. Poole SR, Morrison JD, Adolf A, Reed FM. Paediatric training in family practice: a core curriculum. J Fam Pract 1982;15(6):1145-56.

9. Melville C, Wall D, Anderson J. Paediatric training for family doctors: principals and practice. Med Educ 2002;36(5):449-55.

10. Klein D, Mehta K. Training in adolescent health. How much have second-year resi- dents had? Can Fam Physician 2006;52:980-1. Available from: www.cfp.ca/cgi/

reprint/52/8/980. Accessed 2011 Jan 20.

table 4. Knowledge assessment before and after rotations within groups

GROUP N MEAN SCORE OUT OF 29 (SD) t TEST DEGREES OF FREEDOM P VALUE

Inpatient-ambulatory .048 12 .963

Pretest 13 18.46 (3.431)

Posttest 13 18.38 (5.253)

Ambulatory -4.055 21 .001

Pretest 22 17.41 (3.634)

Posttest 22 20.32 (3.228)

table 5. Confidence assessment before and after rotations within groups

GROUP N MEAN SCORE OUT OF 5 (SD) t TEST DEGREES OF FREEDOM P VALUE

Inpatient-ambulatory -6.399 12 < .001

Pretest 13 2.93 (.364)

Posttest 13 3.62 (.384)

Ambulatory -10.747 18 < .001

Pretest 19 3.04 (.359)

Posttest 19 3.86 (.407)

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