pediatric practice themes summary data – first delta ......pediatric practice themes – delta i...

Pediatric Practice Themes – Delta I Data • October 31, 2006 page 1

Pediatric Practice Themes Summary Data – First Delta Round NOTE: This document reflects the substantive changes that were made minus a few additional last minute edits.

Theme 1a 30 responses (1 person skipped this theme) Response average for 1a = 3.63

Theme 1a: a shift in the causes of health-related morbidity and mortality in children and adolescents from acute to chronic illnesses and disorders. Comments?

1. Is dramatic shift the right phrase? Many factors have contributed to what seems to me to have been an evolution in the health problems pediatricians recognize and spend their time preventing and treating. Education may not have evolved in parallel, but in some cases, pediatric education helped to drive the change. Dramatic shift is, in my opinion, too grand.

2. Chronic disorders have emerged as important. They are not "predominant" in the practice of pediatrics or my subspecialty (infectious diseases), but prominent in reference to need for education re management

3. We should see the data. Infant mortality has certainly not declined in an acceptable fashion, nor has acquired disease from preventable causes. Certainly, we have learned to deal with chronic disease more effectively,

Formatted: Bottom: 1.2"Michael Kaufman ! 1/3/07 6:32 PM

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creating a large population requiring on-going care, but the generalist is not necessarily providing the care.

4. Will the pediatrician be the gatekeeper or the coordinator of care for the children with chronic medical conditions, or will we be the ones managing their chronic conditions? Will we rely on specialists for phone/email consultation only? Do pediatric offices need to have a more multi-disciplinary approach to care?

5. This theme addresses the fundamental model of pediatric care in the US and should we move to a consultative model as in other parts of the world. I agree with Paul Wise that this issue challenges the core mission of pediatrics, can "pediatrics" provide ambulatory care to children with chronic disorders?

6. We must better define the proper interface between general pediatrics care and subspecialty care in terms of referrals, evaluation, and management

7. Our medical systems are set up to respond to acute care much better than chronic disease, so how to provide care in new systems, and how to create better SYSTEMS of delivery are key to our response to the shift in morbidity!

8. Training must include behavioral science as it relates to behavioral change and effective intervention.

9. High prevalence chronic disease is encountered largely in the ambulatory setting. This is where residents need to encounter and provide extended care for these patients. They must do so in the context of care teams.

10. There have been shifts although from a practitioners perspective they may be somewhat less than dramatic. Acute illness and mortality from acute events still, by far, lead the list and probably will continue to do so. The amount of time devoted to the chronic conditions has certainly dramatically increased but, if training is successful might in the future decrease. See Theme 4.

11. There is still significant acute illness occurring for which pediatricians need to be trained to recognize and provide emergency care, at the least

12. These shifts are largely ones of relative frequency; few disorders have disappeared and no class of disorders has vanished. Shifts in where children with various conditions live and are treated are equally important. Genomics is likely to create further shifts from acute illness to chronic disorders to potential conditions.

13. N/A 14. Will still need education about acute illness. We educate those who

choose to do International and 3rd world work, so cannot delete the acute illness.

15. I think some of resident education has already shifted in this area. Residents often have the most complicated CSHCNs in their clinics. The issue is the care of these children (including transition to adult care providers) in the community.


16. My only comment is that acute illness is still an important part of pediatrics--one day rounding on the inpatient unit of a pediatric hospital is testimony to that fact--even severe infections are still with us.

17. The possibility exists that critical uncertainties may impact this trend. Training must address the issue of continued flexibility and adaptability to unanticipated morbidities for example, bio-terrorist impact.

18. These shifts may be epidemiologically driven and vary with geographic distribution, and other demographic variables.

19. Current change in residency schedules to accommodate work hours concerns has impacted the continuity of care, and may have decreased resident exposure to the continuum of care and their overall understanding of chronic disease management. More residents are likely to need this skill set than they will managing neonates, for example.

20. Still need to be able to take care of critical illness, acute illness while adding the others. Also need to have skill in mental health.

21. none 22. There has been a shift in vulnerability that includes chronic disorders but

also social and economic conditions that place certain and significant numbers of children at risk


Theme 1b 30 responses (1 person skipped this theme) Response average for 1b = 3.77

Theme 1b: changes in biomedical and psychosocial knowledge as well as diagnostic and treatment methodologies. These have been accompanied by changes in information technologies that make access to and interchange of information easier for health professionals, patients and families. Comments?

1. What role does medical genetics play? What resources will pediatricians have to counsel families about potential genetic conditions? What training will residents receive in medical genetics? What type of training will residents receive on proper email communication, internet medical use and computer educational resources for patients (for their iPod/PDA)

2. The challenge is to train pediatricians to cope with any new developments that arise.

3. The fertility rate has been and remains low. The production of doctors, and specifically pediatricians, has consistently exceeded population growth. A huge new clinician workforce has been elaborated: PA's and NP's.

4. Pediatricians need to prepared to regularly update their knowledge 5. We have not seen enough innovation in well child care as we have in many

other areas... 6. Medical genetics must be addressed in more depth -the use of EHR, EMR,

information access and analysis, use of email and other communication technologies, CAI in patient education etc all need to be considered

Administrator ! 11/2/06 1:55 PM





dr019001 ! 11/11/06 4:38 PM



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7. Genetics and environmental health sciences are two important examples of deficiencies in current training. Even more importantly, residents must learn how to assess the psychosocial context in which children receive care and recognize the importance of being able to change health related behaviors.

8. Inherent in this theme is the fact that the sheer volume and exponential accumulation of medical knowledge has made, and will continue to make, the full training of a general or specialist pediatrician impossible in a finite training program. Closely related to theme 5.

9. I wouldn't lump communication technologies with the other; important but different. More germane might be the potential for information technologies to assist physicians deal with the first two changes, i.e., changes in knowledge and changes in diagnostic and treatment. As has been said for at least two decades, memorizing is necessary to a point, but we can use other resources, like computers, to assure that our knowledge and management approaches are comprehensive and up-to-date.

10. N/A 11. Learning to work in an electronic environment will be easy for the next

generation! 12. I think the teachers are less aware than the students who are very facile with

the newer technologies. 13. true--no comment 14. Might include a consideration of the patient's access to information and

resultant push to identify and set their own agenda for interventions in the clinical setting.

15. The import of genetics might be even more emphasized here as a result of the human genome project.

16. Health IT is becoming a widespread component of systems-based practice, yet the reasons for this adoption are not well understood by many practitioners, and its potential to improve medicine as a whole is not close to being realized. This component of the health care system needs to be taught more intentionally (directly) to residents.

17. Often the advances in technology are not communicated effectively to primary care providers. The technology gets ahead of the physician/patient interface. We also do not always have ways to ensure that new developments are able to be disseminated to all children (e.g., issues of financing are not always addressed)

18. None


Theme 1c 30 responses (1 person skipped this theme) Response average for 1c = 3.23

Theme 1c: changes in families that tend to impede access to health care, especially more single-parent families and families where both parents work. Comments?

1. This is true, but it seems hardly a blip in the road for pediatrics. After all, the trainees will have grown up in and are a part of this changed society. I don't think this will need a great deal of emphasis.

2. This has not changed much in the poor underserved population in the inner city. That is, there still are not 2-parent households, and women have not entered the workforce to much extent.

3. With both parents working, many families divorcing/blended families...how are residents trained to coordinate care and effectively communicate with all parties involved?

4. Not a major issue to me 5. I was not sure what this means...I think in regard to blended families, same

gender families etc. As I reflect on the theme I agree in many ways, but at the root, aren't families really valuing the same core things they valued years and ages ago? unconditional love, feelings of a safe haven/belonging, and support. It brings to mind a poem (by Langston Hughes- I think) about racial differences: "We are more alike my friends than we are unalike" I think the same applies to families. (sorry to be wordy : ))

6. Prevention is hard when only one household in which the child resides routinely interacts with the medical home.

Administrator ! 11/2/06 2:19 PMDeleted: The structure and composition of families have changed


7. This is an issue to which our residents should be sensitive, but I do not think that it needs a theme all its own. Perhaps it could be collapsed into the theme on diversity, as yet another example of cultural sensitivity.

8. They will keep changing. The issue is not how families are changing but how each family unit is to be assessed for its ability to meet their childs health. Families should be viewed as the primary care giver and interacted with accordingly.

9. This is true in a statistical sense, but may overstate the issues. This needs careful qualification

10. This means two things, at least. First, with more single parents and more children experiencing divorce, family poverty and lack of social support will increase the rate of psychosocial problems and impede families' ability to respond effectively to advice. Second, with most parents at work and most children in child care or school, the usual office practice with office hours of 8:30-5:00 and a few hours on weekends are not conducive to obtaining timely health care, ergo Wal-Mart clinics. We need alternative structures and need to learn how to work effectively in them.

11. N/A 12. While this is certainly true, many "structural" factors are the same: a "parent"

brings in the child to a site of care. 13. For many of us, the families we care for have always been "different". I'm not

sure how this should relate to resident education. 14. There's no doubt that this is true. I'm just not sure how pediatric residency

training should change in response to this fact. We just have to acknowledge that it's true and try to ensure that everyone is included in our discussions about patients and that the impact of this fact on children is considered in our evaluation and management.

15. Increased understanding on the role of the family related to preventive health care, intervention, compliance etc.

16. Need to say more about pediatricians role with adult members of those families (e.g. should we be trained to pick up warning signs of depression etc. in parents and not just our patients)or to differentiate what we do from family medicine physicians.

17. Understanding issues such as same-sex families, home schooling, international adoption, are all reasonable additions to the core knowledge of pediatricians.

18. I don't think this is as big a deal as some of the other themes. 19. Should include all kinds of "families". 20. And the structure of communities and larger society has changed too


Theme 1d 30 responses (1 person skipped this theme) Response average for 1d = 3.63

Theme 1d: The cultural diversity of children and parents has increased, with a corresponding need for effective ways of increasing cultural competence and the cultural diversity of the pediatric workforce. Comments?

1. Very important. We are just beginning to understand what patient centered care is and what the barriers are to delivery quality care that is culturally appropriate.

2. We must recruit a more diverse workforce 3. Recruitment of a diverse group of students into medical school needs to be

addressed before there will be a major increase in diversity in the pediatric training programs. Team care and education with role-models are essential for future trainees. Community work also helps with training in this area.

4. I subscribe to the belief that families within cultures vary more than families between cultures, so rather than be culturally competent, one should be family competent and culturally sensitive. I don't see a quick fix (decades) to the diversity of pediatricians, but if we move to health care teams, especially teams that include community partners, then we will have redefined the pediatric workforce to be more encompassing and will find it easier to achieve diversity.

5. N/A


6. I am too practical. Language time and training need to be part of the curriculum in many programs.

7. We give a fair amount of lip service to cultural diversity - very prominent in some programs and absent in others. Probably less emphasized for practitioners.

8. True--should fluent Spanish be a requirement for medical school? 9. Medicine has traditionally been culturally "blind" assuming one intervention

is appropriate and of value for all. Need additional training on culturally sensitive intervention and complementary and alternative approaches to care.

10. Should we add "assessing" as well increasing cultural competence? Should we say more about recruitment strategies into pediatrics to meet the cultural diversity of the population we serve?

11. This is quite clearly stated and obvious, given the changing US demographic alone, let alone the potential roles pediatricians now play in world health.

12. This is increasingly important with regard to parental trust and compliance with recommended issues such as "back to sleep" and other preventive interventions for which there are disparities in their implementation.

13. begin with high school students in all types of settings.


Theme 1e 30 responses (1 person skipped this theme) Response average for 1e = 3.69

Theme 1e: changes in the expectations of the pediatric workforce, with more individuals seeking part-time employment and in general greater emphasis on family and personal, in place of professional, priorities. Comments?

1. Inherent in this is the cost recovery model of so-called cognitive medicine. Reassessment and realignment of this model is fundamental.

2. Part of training pediatricians to be able to manage their own professional development throughout their careers

3. Great, extremely big issue with my residents, currently! 4. Flexibility is key and must be reconciled with patient satisfaction and

continuity of care 5. I think this is less of an issue than we may think - peds has always been

amenable to part time - however I think that there are generational differences that need to be considered - there will be no more boomers...

6. I dont see this as a critical issue for R3P except in so far as training is flexible.

7. Two thoughts: 1) Residency programs have not addressed this issue well, and thus have not provided models of how pediatricians might work part-time. It still comes as a surprise to residency directors that half their female residents get pregnant. We need to develop shared and part-time residencies as the norm, and need to develop ways to assure continuity of patient care in such








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circumstances. Certainly the 80-hour work week ought to have stimulated some creative approaches to this. 2) The issue of professional obligations, otherwise called "professionalism" seems to be an increasingly important problem within medicine, including pediatrics. This needs to be addressed in a number of ways, but especially through incentives (e.g., recognition) and role modeling during training.

8. N/A 9. This is generational, not just gender based. 10. We are seeing a concern about balance not just for women but also for men -

more generational than gender-specific. This is also an outgrowth of the 80 hour duty week.

11. I think this is old news. Individual pediatricians are already figuring this out. 12. This speaks to societal changes but threatens the moral values of the

profession that put patients first. New systems of care and education should support flexibility in training and certification.

13. We need to find areas of imbalance in the workforce and improve the situation so that all areas of our profession can be accessed by those who have an interest in that area (e.g. part-time women being discouraged from research careers--i.e. fellowships)

14. This is an big issue for specialists and research in the field of pediatrics. 15. Great idea and currently being done but there are few PT MD's especially

women willing to take on the responsibilities of partnership, legal and financial within a primary care practice. This will cause a decline in the current number of primary care practices who would like to sell at retirement.

16. it is not just women in pediatrics-- women are now in the workforce much more than 30 years ago and this makes for added challenges for all families, including those with women and men who are pediatricians


Theme 1 The following chart shows themes 1a – 1e in one chart.

The following chart shows the average responses for themes 1a – 1e sorted highest to lowest. The average is calculated by using the values of 1 for strongly disagree, 2 for somewhat disagree, 3 for somewhat agree and 4 for strongly agree.


Theme 2 30 responses (1 person skipped this theme) Response Average = 3.67

Theme 2: General pediatricians will continue to exemplify a comprehensive approach to health care for children and adolescents, especially those with chronic physical, mental, developmental and behavioral disorders. Pediatric education must ensure that distinct pediatric expertise in this regard is developed and maintained. Comments?

1. Not sure I understand what "differentiated" means here. 2. Not certain of the evidence for this. As a sub-specialist, I do not see the

generalist spending much time with chronic or time-consuming issues. Perhaps, in other areas of the country, this may not pertain.

3. we need different pathways for residents to choose in their training to meet their needs for the type of job they will choose.

4. Important. Pediatricians have an opportunity to be population health managers which will require multiple skills.

5. Care across settings is crucial. Will pediatricians go to the hospital, the ED, the home?

6. Teamwork and better interfaces with allied health care and other providers 7. Yes, I hope we will continue to do so, but so much hinges in how we can get

funded to do this!! And to provide comprehensive mental-dev-beh health will require new ways to share information with mental health providers to truly provide integrated care!!

8. There must be much more training in peds psychiatry and psychology

Administrator ! 12/13/06 3:25 PMDeleted: differentiateddifferentiated


9. Somewhere we need to address the possibility that at least some practices may evolve to more the Canadian consultative model and teach even general pediatricians how to be good consultants.

10. I dont think the first sentence is generally true today. Doo we want to force change by curricular mandates? I'm not sure it will work.

11. Pediatrics differentiates itself from internal medicine not only by the age of our patients but by the fact of their pronounced developmental changes. Pediatricians of all stripes need to have a better understanding of the underlying physical and emotional development of children in order to provide the best quality care. This needs to be a formal part of education/training. All pediatricians need to be sensitive to and able to begin to address the emotional and behavioral responses and adjustments children and families need to make in the face of serious illness. Primary care pediatricians, except in underserved areas where access to subspecialists is severly limited, need to be expert in the conditions which are most prevalent among children, i.e., chronic illness and behavioral-developmental problems, and in their prevention. Otherwise, there is little justification for their work. This probably means that those going into "typical" pediatric primary care practice, need to have specific, demonstrable expertise in these aspects of pediatric care that is at least equivalent to, and probably greater than, their skill in managing acute illness.

12. N/A 13. I believe we need a separate them with emphasis on the need to learn about

behavioral and psychiatric issues. The workforce for this is extremely small and Pediatricians will need to be involved.

14. I think the generalist must remain at the heart of pediatrics and as the advocate for the medical home.

15. Agree, but some of the education and expertise needed will continue to occur AFTER residency training--there just isn't the time, and residents aren't ready, to do all this early in the career.

16. This provides a baseline for knowledge, skills and attitudes that would enhance the pediatritions added value in managing care centers that might be additionally staffed by nonphysician providers.

17. ...developed and maintained and appropriately valued in the workforce going forward given the shortage of other health care providers who can provide these services to pediatric patients.

18. Medical students should have a least a semester of primary care in an outpatient setting as part of their experience. Not just clinic but private practice.



Theme 3: The professional practices of pediatricians in large cities with ready access to subspecialsts tends to differ from practices in a smaller city or rural location; roles also vary with the staffing structure of the practice in which one works. Pediatric education needs to acknowledge this diversity of roles. Comments?

1. Not quite sure what this means. That pediatricians in training must be aware that other folks are taking care of children? That pediatric education must prepare for a variety of settings?

2. Residents need to learn how non physician providers fit into the "team" of the practice they are in and know that not only that pediatricians will work to help patients, but they also need to be teacher/supervisors/educators and life long learners.

3. An ideal educational setting and a model educational program may be more important than trying to educate pediatricians in a variety of settings just for the sake of exposure

4. non-physician providers in department stores, is this a passing trend or a huge new movement? hard to know, but we need to address!

5. The concept of the pediatrician as a team leader is key. However Pediatricians must still be trained to take care of emergencies and stabilize very sick children

6. yes

Administrator ! 11/2/06 3:51 PMDeleted: Pediatric health care is delivered in a variety of clinical and geographic settings by a variety of physician and non-physician providers. This trend is likely to continue and must be reflected in pediatric education.


7. Need to acknowledge the variety of patient and family needs for health care 8. Training and maintenance of certification need to be individualized to allow

development and demonstration of the competencies required in the geographic setting (and its associated patterns of morbidity and referral resources) in which pediatricans intend to and do practice.

9. N/A 10. Who will provide primary care. This is the crux of the issue for the USA. We

have a unique model -- different from the rest of the world and perhaps it should evolve.

11. I think the issue of rural healthcare, though real is less a driving force in shaping pediatric residency education. It is key that there be sufficient flexibility to allow programs to permit residents to take additional or unusual rotations to meet their future professional needs.

12. Yes. Pediatric residents (and medical students) should have opportunities to work with other providers--I think this is happening and shouldn't take lots of our time.

13. It should be recognized that nonphysician providers continue to evolve as a group and that the residency project and pediatric health care can not be considered in a vacume. Dialogues should begin with other professions beginning with the patient's needs and working to find backwards to determine who is best suited to meed those needs. There is added value to all disciplines.

14. The role of the pediatrician as a first-line primary care provider may need to be reevaluated given the first-line roles of other types of health care professionals also trained for first-line contact in primary care. Similarities with others and added advantages of pediatricians doing primary care need to be addressed.

15. Medical students should be exposed to other health care providers especially nurse practitioners who provide a good majority of health care in the clinical setting especially in inner city clinics and some private practices.



Theme 4: Pediatric health care is increasingly delivered by teams of professionals from health care and the community working in concert with patients and parents. Pediatric medical education must foster the development and maintenance of the leadership, collaboration and communication skills needed to function within these teams. Comments?

1. Same comment with respect to medical economics. 2. Critically important but should also include the collaboration across settings

(local teams collaborating with other geographically distinct practices in regional and national efforts)

3. Communication skills must be taught and practiced - this is rarely done and cannot be left to chance

4. yes yes yes 5. Need to recognize that there are still many non- team child/family/physician

encounters. 6. Current skills training in communicating with patients and with other

professions is generally inadequate. Successful interventions absolutely depend on conveying our advice in ways that will lead to new or different behaviors by children and families; the most brilliant diagnosis doesn't matter if adherence is not obtained. Small group learning should be the norm in








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medical and residency education. Family and community members should help shape pediatric education.

7. N/A 8. Residency training must include team building, conflict resolution, leadership

training. 9. Most training programs incorporate the team concept into the residency

experience. Residents however, may be peripheral to the team, with decisions being made by faculty. The challenge is to have the residents feel like they too are active participants in decision-making.

10. Absolutely--and one of the means to achieve this is to accommodate to the 80-hour work week during residency training. We have to acknowledge that no one provider can be responsible for everything, 24/7.

11. This training should occur in teams with other health care professionals. Only through modeling and experience will this concept of "team" care be realized.

12. Advocacy training and understanding of community-based health care are critical to achieving this collaboration.

13. Residency programs need to involve residents in the system of practice, beyond the walls of a hospital. Whether this be like Seattle's WAMI program (extended immersion exercises) or simply different rotations that emphasize teams should be discussed.

14. All medical students should be exposed to various community health care providers in order to refer patients and have the appropriate follow up. Such at PT, OT and speech. School settings are another area which most physicians are unfamiliar with.

15. To truly impact the epidemiology of of health issues in a community, pediatricians must work with community leaders too



Theme 5: No single educational methodology will suffice for pediatric education. The general principle, however, is that education needs to facilitate active personal ownership of learning: the process of training must foster reflective practice and develop the skills of self-directed lifelong learning. Comments?

1. Could not agree more. With respect to the comment on 4th year medical school, this would be an excellent time to promote early training for those with clear career plans.

2. Pediatricians have a professional obligation to assess and continue to improve their own professional development in conjunction with assessing and improving the quality of care they and their care team deliver

3. In my additions I listed suggestions for 5a, and 5b. Just thoughts, but we really should educate the educators!! Language to that effect may be important here.

4. Journaling, Balint groups, true mentoring in patient care etc will foster development of these skills

5. This is the theme that I feel should be number one, because it is a key frustration to so many of us with the "cookie cutter" RRC requirements.

6. Need to add something on incremental independent decision making during education and promotion of personal physician sense responsibility for patients he or she cares for.


7. Trust but verify. 8. N/A 9. Should there be a theme that we base care on the best evidence? EBM as a

founding principle? 10. Agree. There is also a lot of activity related to CME and individualizing

educational experiences so they are not simply being talked at. 11. Yep 12. Agree, personal ownership and recognition of learning needs are important.

Given the discouraging literature on self-assessment, education must include or at least investigate, whether these skills of self-observation can be taught. Perhaps like everything else, they must be modeled and taught in context.

13. The use of educational technology may facilitate the ability to foster and monitor self-directed learning.

14. None



Comments?

1. Too tactical to be one of our overall themes. 2. This seems to me to be an issue that the national pediatric organizations and

leaders should address in a separate task force 3. The financing of clinical education is HUGE as a barrier or enabler. This is

correct and so understated. 4. A necessary step in fueling innovation and sustainable educational initiatives 5. Agree with the need to support out of hospital training, but we desperately

need to provide direct funding to the teachers/instructors everywhere including in the hospital, as they, too, are being squeezed out of support!

6. The entire funding system needs to be blown up and re-thought. Mission based budgeting - those who allow achievement of the goals and objectives should get the money. This will require discussion and negotiation on a state and federal level.

7. I don’t see this issue as being central to the ABP agenda. Set up training where ever it is best carried out and the dollars are likely to follow--eventually.

8. This is a major problem and will require a fundamental shift in how medical education is supported. However, achieving this shift is essential and needs to be addressed head-on and soon.

9. N/A

Administrator ! 11/2/06 4:22 PMDeleted: Theme 6: Education funding, currently tied to hospital-based practice, should follow the trainee to all appropriate education venues.


10. The Feds will like this one. 11. I think this is critical but could be distracting for R3P to focus on. 12. True--but this might be bigger than we can tackle. 13. Should this be stronger--as written it makes a statement but carries no clout.

Should the "should follow" become a "must follow" to wake up those who fund the education that is largely hospital-based.

14. None



Theme 6: The principles of continuous quality improvement need to be taught as such and by example. Both patient care and education need to be based on evidence where evidence exists, and both need to be continuously re-evaluated according to measured outcomes. Comments?

1. An essential core competency that requires experiential learning. The challenge for medical education is to integrate education with the delivery of quality care so that residents experience quality improvement in the daily work of delivering care.

2. excellent 3. This is everybody's business and must drive the educational agendas 4. Add to that professionalism. The culture of medicine needs to change so that

these principles are taught from entry into medical school. 5. absolutely 6. An aspect of pediatric education that has gone from non existent to one of the

most important and useful skills that a trainee must acquire. Should be thought of in the context of one of those skill that must start in med. school. See theme 9

7. The need for faculty education in regards to these issues needs to be stated. 8. After medical school (?) all education should be presented as quality

improvement. All teaching, to the extent possible, should include data on





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performance. Where data doesn't exist, it should be collected, even in a rudimentary way.

9. N/A 10. It seems that there are those with interest and expertise in this area, and others

(perhaps the majority) who tune out whenever the topic arises. Perhaps the reason is that in many institutions there are committees that address QI, and the rest of the staff seem only remotely involved.

11. Yes 12. Perhaps research and advocacy should also be included so that all aspects of

our profession are looked at from a standpoint of CQI. 13. This is extremely important. Feedback about resident practice should be

integrated into their rotations in a more quantitative fashion. Topics such as guideline adherence, communication, potential ADEs, etc, should be evaluated during each rotation. Residents should be involved, as well, in giving this feedback.

14. None



Theme 7: Pediatric health care is patient- and family-centered. The advice and counsel of patients and parents must be utilized in the design of education programs for pediatricians. Comments?

1. Don't know exactly what "evident" and "all aspects" means. Parents' attitudes about what they perceive as good care should be solicited and considered. Parents however, would not be appropriate to weigh in on curricular science-related content.

2. This theme needs to be expanded to the concept of patients and parents as active members of the care team, not just giving advice and counsel.

3. Given the challenges children face in becoming healthy, their parents and communities are UNAVOIDABLY in the domain of the pediatrician. The division of care away from parents and other caregivers is not cast in concrete.

4. Comments from consumers, 360 degree evaluation all helpful - hard to do consistently and reliably.

5. a central tenet of pediatric care and training. Lets make it clear who the real caregivers are before another generation of pediatricians is misled.

6. This to broad a statement. I do not agree with "all". 7. It should be required, not just "valued". In addition to advisory processes, all

clinical care should include a focus on the problem as identified by the patient/family and should take into account the preferences and priorities of








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the patient/family. Negotiated care is the only way to truly have patient- and family-centered care.

8. N/A 9. Family centered care is critical. I have some reservations about having

families decide what is taught in its entirety. There are those who will need to learn what appears, at first glance, to be unnecessary.

10. This is the heart of humanism and is critical to teach and emphasize. 11. I don't think there's anything new in this. 12. Parents and families are our best teachers. As such they should be included in

our formal teaching programs. Some excellent models for this already exist. 13. I think this is well stated in that it notes the strong involvement of families,

but does not make them the drivers at the expense of the pediatricians themselves.

14. Patients and families play an important role in the measurement of clinical care - and quality improvement methods. Not sure I agree with the broadness of the theme as it is stated.

15. Definitely



Theme 8: The expectations for pediatric education must be articulated and staged along the educational continuum from medical school to resident education to continued, career-long professional development. Better use of the fourth year of medical school should be explored. Comments?

1. "...underutilized as the beginning of practice-based curriculum." 2. I am unsure about this. Curricular content is important but will and should

change over time. How do we create programs that focus on learning and are more flexible and willing to change as content focus changes?

3. A tough problem to solve 4. And premed requirements are probably missing the point in some domains

too. 5. Showcasing for residency and the rush to do ICU rotations so that students

feel "prepared" needs to give way to a focus on core skills and objectives. 6. In general but lets not get too prescriptive. 7. We should learn from pilot programs that have been successful in the past

like the FM use of the 4th year of medical school as the first year of residency. I think that better use of that fourth year for those who have already begun a career path is essential.

8. Agree. We need a plan, not just a process. 9. N/A






Deleted: 9

Deleted: 9

Deleted: curricular content and

Deleted: T

Deleted: is often underutilized in this regard


10. The 4th year could be useful in career preparation but should not be limited to only Pediatrics.

11. Also critical to not fragment education but to view it as a continuum. I think there is too much elective time in medical school and many students have no idea what they need to know for the future. I believe in greater structuring and more requirements to be certain that students are in fact prepared for residency.

12. Yes--I think a national, post-match pediatric curriculum, required for future pediatric residents--should be developed.

13. Collaboration with undergraduate medical education leadership organizations (e.g. AAMC and COMSEP) and the AAP will be critical in developing and implementing this theme.

14. yes, there should be rotations outside the hospitial to promote the primary care aspect of medicine not the specialist.

15. C Everett Koop said in Health Affairs reflecting back on his career that "In the long run, child health is about advocacy." Where and when do we teach that?



Theme 9: Education in general pediatrics must be flexible, acknowledging the diversity of pediatric practice and the variety of practice settings that exist now and will exist in the future. The current model of generalist education needs to be compared with alternatives that allow for greater differentiation according to career goals. Comments?

1. A focus on the process of learning and development rather than defined content

2. well-worded 3. As we accept diversity in training focus, we need to maintain enough of a

PEDIATRIC VISION, to be know who we are and what makes us "pediatricians" ... e.g., urban pediatricians with easy access to sub-specialists, should not come out looking like non-physician providers, etc.

4. What does a generalist in a rural setting need to know and be able to "do"? Is it the same as someone who is going to be a hospitalist ? a neonatologist? a generalist in an urban setting with tertiary care hospitals. Is it the job of the residency to train for all "setting" should residency be shorter and there be fellowships in "general pediatrics" for everyone taking that path?

5. I'd put this as Theme 1 6. Amen. We need to decide where we're going. Identify the barriers to getting

there. And create solutions to those barriers. This means differentiated training, and probably differentiated certification.






Deleted: 10

Deleted: 10

Deleted: three years of relatively undifferentiated

Deleted: training

Deleted: reexamined


7. N/A 8. Track for generalist/sub-specialist were proposed many years ago and should

be reevaluated. 9. I think there needs to be flexibility but don't agree with the statement that the

current generalist is "relatively undifferentiated." Sounds too pejorative. I suppose the AAP may be helpful in having generalists (practitioners) help elucidate the gaps (other than CPT coding!)

10. If this means taking the team leadership role away from PL3's, I'm very much against it. I still think we should know what to expect when someone identifies themselves as a pediatrician, and that development of the judgment, confidence, teaching ability, knowledge, and responsibility that I see developing in PL3s is one of the most important developmental tasks of residency training.

11. Agree. 12. Multiple models will need to be explored and possible differentiation tracks

developed that are either competency or length of training based or a combination of both.

13. There should be 2 tracts for education. Specialists and primary care with the emphasis on specific educational goals within each discipline.



Theme 10: Certification and maintenance of certification need to be correspondingly flexible. Maintenance of certification must be able to accommodate reentry into practice after prolonged absences as well as mid-career changes in the type of practice. Comments?

1. MOC should be flexible, relevant, integrated into practice, should reduce redundancy and improve patient outcomes

2. Vital to the process so that not all effort is focused on residency training 3. The idea of answering MCQ questions to re-certify is not adequate - there

needs to be a portfolio method that looks at practice skills etc. 4. yes, but not a big deal 5. As more "niche" practices evolve because of the explosion of knowledge and

the unforeseen development of new fields in general pediatrics and the sub-specialties this will become most important and must be accomplished. Obviously closely related to theme 7.

6. And needs to accommodate different types of pediatricians at the outset. However, there have to be basic competencies regardless of the ultimate path.

7. N/A 8. Certification should be a continuous process, not an occasional examination.

It should also be useful to the practitioner -- helping him/her to improve the quality of practice. The ABP is moving in this direction.



Deleted: 11

Deleted: 11


9. I think that the focus should be less on certifying or attesting to one's competences, and more on promoting education and attainment of competencies. I have concerns that the secure exam has placed undue emphasis on that component of MOC and detracted from continued learning and improvement. I think there need to be ways to better integrate MOC so that the 4 component parts do not seem disconnected.

10. I'm not so sure. It depends upon how prolonged the absence, and what sort of career change is involved.

11. Perhaps it is time to think outside the box about new models for certification and maintenance. One might speculate that these models would need to be incorporate early into our education systems in order to be effective.

12. This seems an ABP issue that is being tacked on to the primary goal of how we train residents following their undergraduate education. This is an important topic--but it seems that it is something that should be addressed after we look at the big elephant in the living room first.

13. good idea


Suggested Theme: Delphi feedback Theme 11: The “basic science” requirements for the study of pediatrics should be re-examined and possibly modified in content and timing of learning. Theme 12: Evaluation for achievement of clinical competencies during residency requires competent evaluators. Programs to assure competency in evaluation are needed. Theme 13: Pediatric residents are closely supervised; opportunities for independent decision making, even for advanced residents, are limited. The period of transition from residency to workplace or to the next phase of training and education has become a progressively important and should be critically analyzed.


Summary Data The following graph shows themes 2 through 11 on one chart.


The following graph is the average response for each theme sorted in descending order. The average is calculated by using the values of 1 for strongly disagree, 2 for somewhat disagree, 3 for somewhat agree and 4 for strongly agree. This type of chart would be one way to view which, if any, of the themes stands out as one to be considered for removal. In this case all themes average between somewhat agree and strongly agree so none of them should necessarily be removed. Theme 1c might be looked into for improvement based on the comments received (the comments received about each theme might help to adjust how they are stated but this chart shows theme 1c as standing out from the rest).


The following graph is called a control chart. It is called a control chart because one of the things it shows is whether or not the variation in a system is inherent within the system or if any of the variation might be caused by something ‘outside the system.’ One thing it shows is which variable, if any, falls ‘outside the control limits.’ Any data point falling outside the control limits would need to be looked into further to discover why it is different from the other points. The chart below shows all data points falling within the control limits hence that would imply no need to look deeper into the reasons why one point is higher or lower than another. Legend – the themes are plotted in green (what is plotted is the average score for each theme). The upper control limit (4.0) is yellow, the lower control limit (3.16) is blue. The average of the averages (3.63) is plotted in red.


Suggested Additional Themes The following are the suggested additional themes in their raw form (just as we received them). In a separate document we will attempt to sort these into like groupings – and where it seems likely, attach some of these suggestions to existing themes. What additional themes should be added to guide our work?

1. Pediatricians are advocates for the health of the child population and, to be effective, must understand the principles of public health.

2. Expectation of "post-training training" should be emphasized and curriculum developed

3. Attention should be given to the trainees future goals and provide an appropriately balanced yet flexible education and training

4. Outcome based medicine: this theme is embedded in the concept of quality improvement but should be made explicit. Physicians have a professional obligation to measure the impact of what they do

5. 5a. The educators of pediatric residents should be well trained and experienced in all facets of medical education, such that these educators can facilitate life long learning concepts in training.

6. We need to anticipate, consider and develop a response to non-traditional service providers is - urgicare in WalMart, licensed independent nurse practitioners, etc.

7. Issues of patient safety that impact the training of residents need to be considered -, in particular in high complexity areas of care such as the NICU and PICU.

8. Flexibility in residency education should also be based on the strengths of the training program. Centers of educational excellence should be established to foster dynamic, quality-driven change.

9. Personalized, predictive medicine 10. Capacity to deal with medical emergencies should be maintained 11. Effectively addressing children's health will require formal collaboration and,

in some instances integration, with other services and professionals that serve children and families

12. An analysis/evaluation of the current model of primary care should be completed. This would provide data about a potential necessary change in our current model.

13. Humanism as a key component 14. Some acknowledgement of the importance of the health of children

throughout the world should be incorporated into residency training in general pediatrics.

15. The impact of informatics on patient access to information. 16. Assessments must be designed to do more than just evaluate cognitive

competency given the other attributes needed to train a competent pediatrician as described in the above themes.

17. Values as well as knowledge and skill should be clarified and reinforced during the formation of the pediatrician


18. Cooperative work with other health care professionals has lessen the exposure to procedural practice opportunities - the ability to perform elementary tasks such as phlebotomy remains necessary.

19. The need to address community and environmental determinants of health in order for children to be healthy e.g. to address problems like obesity, violence, child abuse and neglect, mental health

20. The so-called "basic science" requirements for the study of medicine (both pre-med and undergraduate med) should be re-examined and possibly modified both in content and in timing.

21. Training should reflect the requirements for developing future care providers and not service needs at the time. This is not the case at present.

22. Patient centered care: This is much more than Theme 8, it involves patients and parents as part of the care team

23. 5b. The structure of residency training with respect to educational principles should be evidence based, and well studied.

24. A missing theme is about money; There has been a huge influx of cash into healthcare, not proportionate to children.

25. Pediatrics grew out of the public health model and training must embrace community and public health models of healthcare delivery

26. Innovation, research training 27. The need for incremental increases in independent decision making during

residency training is of critical importance in educating residents 28. Pediatric education must emphasize adherence to agreed upon standards of

care and practice and be informed by the best available evidence 29. We need a theme dealing with the current shortage of sub-specialists to

provide necessary care to children and a strong recommendation of FOPE II. 30. The value of the personal relationship: healing as an art 31. There should be some articulation of the expectations for general

pediatricians caring for children with chronic conditions, as compared to the expectations for the sub-specialists caring for those pts

32. Changes in educational requirements such as faculty presence and work hour regulations challenge decision-making and accountability/continuity to patients and must be reemphasized.

33. The importance of early childhood and childhood in determining health trajectories for individuals: pediatrics is where health behaviors and social determinants play their biggest role

34. Collaboration: This is a broader theme than care delivered in teams and addresses the issue of institutional and professional autonomy

35. Consideration must be given to ho much hi-technology, complex care training is appropriate for an undifferentiated resident.

36. Outcomes to guide improvement 37. There should be a theme -- mentioned in #2 -- that the increasing

"behavioral/new morbidity" issues require more specific training for the generalist.

38. Environmental issues and inadequacies in childhood mental health system create need for psychological/behavioral skills.


39. The need to collaborate with non-medical leaders to promote health and well-being for children

pediatric practice themes summary data – first delta ......pediatric practice themes – delta i...

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