Daniel J. Schumacher

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

The Quest Toward Unsupervised Practice: Promoting Autonomy, Not Independence

The ultimate goal of graduate medical education has often been described as supporting learners in the pursuit of independent practice. To achieve this goal, learners and supervisors attempt to balance autonomy vs supervision, defining autonomy as allowing a learner to make decisions in the absence of a supervisor, and supervision as ensuring that ultimate care decisions are in the control of a more experienced physician. These definitions are not only outmoded but perhaps were never correct. Instead, training must prepare learners for unsupervised practice, in which they interact with others (not act independently) and are afforded appropriate autonomy and levels of supervision during training. Indeed, this concept is now reflected in the educational competencies that have been developed by the Accreditation Council for Graduate Medical Education. It is not simply a matter of semantics. Overemphasis on independent practice as the goal beyond training threatens the openness of learners to seeking help when needed and misstates the goal they must strive to achieve. Without defining the intended goal— unsupervised practice—learners and supervisors risk losing focus on ensuring that learners make appropriate de

Medical Student Self-Efficacy with Family-Centered Care during Bedside Rounds

Purpose Factors that support self-efficacy in family-centered care (FCC) must be understood in order to foster FCC in trainees. Using social cognitive theory, the authors examined (1) how three supportive experiences (observing role models, practicing for mastery, and receiving feedback) influence self-efficacy with FCC during rounds and (2) whether the influence of these supportive experiences was mediated by self-efficacy with three key FCC tasks (relationship building, information exchange, and decision making). Method Researchers surveyed third-year students during pediatric clerkship rotations during the 2008–2011 academic years. Surveys assessed supportive experiences and students’ self-efficacy both with FCC during rounds and with key FCC tasks. Researchers constructed measurement models via exploratory and confirmatory factor analyses. Composite indicator structural equation models evaluated whether supportive experiences influenced self-efficacy with FCC during rounds and whether self-efficacy with key FCC tasks mediated any such influences. Results Of 184 eligible students, 172 (93%) completed preclerkship surveys. Observing role models and practicing for mastery supported self-efficacy with FCC during rounds (each P < .01), whereas receiving feedback did not. Self-efficacy with two specific FCC tasks—relationship building and decision making (each P < .05)—mediated the effects of these two supportive experiences on self-efficacy with FCC during rounds. Conclusions Both observing role models and practicing for mastery foster students’ self-efficacy with FCC during rounds, operating through self-efficacy with key FCC tasks. Results suggest the importance both of helping students gain self-efficacy in key FCC tasks before rounds and of helping educators implement supportive experiences during rounds.

Gender and Generational Influences on the Pediatric Workforce and Practice

In response to demographic and other trends that may affect the future of the field of pediatrics, the Federation of Pediatric Organizations formed 4 working groups to participate in a year’s worth of research and discussion preliminary to a Visioning Summit focusing on pediatric practice, research, and training over the next 2 decades. This article, prepared by members of the Gender and Generations Working Group, summarizes findings relevant to the 2 broad categories of demographic trends represented in the name of the group and explores the interface of these trends with advances in technology and social media and the impact this is likely to have on the field of pediatrics. Available data suggest that the trends in the proportions of men and women entering pediatrics are similar to those over the past few decades and that changes in the overall ratio of men and women will not substantially affect pediatric practice. However, although women may be as likely to succeed in academic medicine and research, fewer women than men enter research, thereby potentially decreasing the number of pediatric researchers as the proportion of women increases. Complex generational differences affect both the workforce and interactions in the workplace. Differences between the 4 generational groups comprising the pediatric workforce are likely to result in an evolution of the role of the pediatrician, particularly as it relates to aspects of work–life balance and the use of technology and social media.

Assessing and Managing the Social Determinants of Health: Defining an Entrustable Professional Activity to Assess Residents' Ability to Meet Societal Needs

From the Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Klein); Department of Pediatric Emergency Medicine, Boston University School of Medicine, Boston, Mass (Dr Schumacher); and Department of Pediatrics and Public Health, Boston University Schools of Medicine and Public Health, Boston, Mass (Dr Sandel) The authors declare that they have no conflict of interest. Address correspondence to Melissa D. Klein, MD, MEd, Department of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 (e-mail: Melissa.klein@cchmc.org). Received for publication November 1, 2013; accepted November 1, 2013.

The pediatrics milestones: a continuous quality improvement project is launched-now the hard work begins!

From the Association of American Medical Colleges, Washington, DC (Dr Englander); Department of Pediatrics, Dayton Children’s Medical Center and the Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke); Winthrop University Hospital, Winthrop, NY (Dr Guralnick); Departments of Pediatrics and Internal Medicine, University of Minnesota Amplatz Children’s Hospital and the University of Minnesota School of Medicine, Minneapolis, MN (Dr Benson); Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Hicks and Ludwig); Department of Pediatrics, Boston Children’s Hospital/Boston Medical Center and Boston University School of Medicine, Boston, Mass (Dr Schumacher); Dartmouth Institute for Health Policy and Clinical Practice Center for Leadership and Improvement, Hanover, NH (Ms Johnson); and American Board of Pediatrics, Chapel Hill, NC (Dr Carraccio) Address correspondence to Robert Englander, MD, MPH, Association of American Medical Colleges, 2450 N Street NW, Washington, DC 20037 (e-mail: renglander@aamc.org).

Relationships Between Program Size, Training Experience, and Career Intentions: Pediatrics Resident Reports From 2010 to 2014

OBJECTIVE To determine the relationship between pediatric residency program size and resident demographic characteristics, career intentions, and training experiences. METHODS Annual national random samples of 1000 graduating pediatrics residents were surveyed between 2010 and 2014. Response years were pooled for analysis, and trends in resident demographic characteristics, career intentions and job search, and training experiences were compared across program class size: small (<10 residents per class), medium (10-19 residents per class), and large (≥20 residents per class). RESULTS Overall response rate was 61% (3038 of 5000). Primary care goals at the end of residency varied according to program size: 45.9% for small programs, 43.4% for medium programs, and 35.1% for large programs. Reports of excellent or very good preparation for subspecialty fellowship and hospitalist positions increased across program size, whereas primary care preparation reports decreased. Only half of the residents in large programs who enter primary care believe they are prepared and less than half in small programs who accept subspecialty fellowship positions believe they are prepared for these new positions. Residents in medium and large programs report being most prepared for hospitalist work. CONCLUSIONS Notable numbers of residents in small programs pursue subspecialties and notable numbers in large programs enter primary care. However, residents believe they are less prepared for primary care as program size increases and less prepared for subspecialty training as program size decreases. These findings suggest that the training experiences of some residents do not optimally align with their future practice.

The Initiative on Subspecialty Clinical Training and Certification (SCTC): Background and Recommendations

* Abbreviations: ABP — : American Board of Pediatrics ABMS — : American Board of Medical Specialties ACGME — : Accreditation Council for Graduate Medical Education CBME — : competency-based medical education EPA — : entrustable professional activity FOPO — : Federation of Pediatric Organizations MOC — : Maintenance of Certification SCTC — : Subspecialty Clinical Training and Certification The American Board of Pediatrics (ABP) certifies general pediatricians and pediatric subspecialists based on standards of excellence that lead to high-quality health care during infancy, childhood, adolescence, and the transition into adulthood. Thus, central to the ABP’s mission is assurance to the public that a general pediatrician or pediatric subspecialist has successfully completed accredited training and fulfills the continuous evaluation requirements that encompass the 6 core competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). The ABP’s quest for excellence is evident in its rigorous evaluation process and in new initiatives undertaken that not only continually improve the standards of its certification but also advance the science, education, study, and practice of pediatrics. The ABP’s responsibilities and authorities in standard setting and evaluation overlap through interest and influence the responsibilities and authorities assumed by the ACGME through its Pediatric Review Committee in the area of training, as well as those of the American Academy of Pediatrics and the subspecialty societies with respect to advocacy and education. Although the respective organizations have distinct missions and roles, they often work in collaboration and synergy regarding training and advocacy. Nonetheless, standard setting, evaluation, and certification remain the sole purview of the ABP. Because of the centrality of accredited training to certification, a decision by the ABP to offer a subspecialty certificate leads to a petition to the ACGME to accredit training programs. The ABP provides substantial input to the development of initial subspecialty program requirements and periodic revisions through its respective subboards, and the ABP standards for certification heavily influence the content of program requirements. In the late 1990s, the ACGME and ABMS introduced the concept of competency-based medical education (CBME) with the establishment of 6 domains of competence: patient care, medical knowledge, practice-based … Address correspondence to David K. Stevenson, MD, Harold K. Faber Professor of Pediatrics, Stanford University School of Medicine, Medical School Office Building, 1265 Welch Rd, X157, Stanford, CA 94305. E-mail: dstevenson{at}stanford.edu

Domain of Competence: Patient Care

From the Boston Combined Residency Program in Pediatrics, Pediatric Emergency Medicine, Boston Medical Center, Boston, Mass (Dr Schumacher); Association of American Medical Colleges, Washington, DC (Dr Englander); Department of Clinical Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (Dr Hicks); Competency-Based Assessment, American Board of Pediatrics, Chapel Hill, NC (Dr Carraccio); and Office of Graduate Medical Education and Student Affairs, and Department of Pediatrics, Winthrop University Hospital, Mineola, NY (Dr Guralnick) The views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for Graduate Medical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association. The authors declare that they have no conflict of interest. Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors. Address correspondence to Daniel J. Schumacher, MD, MEd, One Boston Medical Center Place, Boston, MA 02118 (e-mail: daniel. schumacher@bmc.org).

A multi-source feedback tool for measuring a subset of Pediatrics Milestones

Abstract Background: The Pediatrics Milestones Assessment Pilot employed a new multisource feedback (MSF) instrument to assess nine Pediatrics Milestones among interns and subinterns in the inpatient context. Objective: To report validity evidence for the MSF tool for informing milestone classification decisions. Methods: We obtained MSF instruments by different raters per learner per rotation. We present evidence for validity based on the unified validity framework. Results: One hundred and ninety two interns and 41 subinterns at 18 Pediatrics residency programs received a total of 1084 MSF forms from faculty (40%), senior residents (34%), nurses (22%), and other staff (4%). Variance in ratings was associated primarily with rater (32%) and learner (22%). The milestone factor structure fit data better than simpler structures. In domains except professionalism, ratings by nurses were significantly lower than those by faculty and ratings by other staff were significantly higher. Ratings were higher when the rater observed the learner for longer periods and had a positive global opinion of the learner. Ratings of interns and subinterns did not differ, except for ratings by senior residents. MSF-based scales correlated with summative milestone scores. Conclusion: We obtain moderately reliable MSF ratings of interns and subinterns in the inpatient context to inform some milestone assignments.