Gail A. McGuinness

Recently Trained General Pediatricians: Perspectives on Residency Training and Scope of Practice

OBJECTIVE. Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training. METHODS. A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4–5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1–2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice. RESULTS. The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care. CONCLUSIONS. The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.

The silent ductus arteriosus

Preterm infants at risk of developing a patent ductus arteriosus were followed sequentially by physical examination, echocardiographic determinations of the LA/AO ratio, and chest roentgenograms. The results show that a significant number of infants who have no clinical signs or symptoms of a PDA have large left-to-right shunts. The presence of this shunt was suggested by acute increase in left atrial size by ECHO determination and confirmed by retrograde single-film aortography. Clinical signs and symptoms often developed several days after documentation of the left-to-right shunt.

General Pediatrics Resident Perspectives on Training Decisions and Career Choice

OBJECTIVE. Little is known regarding at what point during the training period residents in pediatrics make decisions on their future career choices. As part of a dedicated process of reexamining the structure of residency training in pediatrics, the American Board of Pediatrics sought information to better understand the influences, process, and sequencing of both residency program selection and career decision-making among residents. METHODS. All pediatrics resident physicians in all training programs in the United States and Canada (N = 8290) received the survey as part of the general pediatrics in-training examination. The survey focused on exploring how and when pediatrics residents make career choices and assessed perceived flexibility of their individual pediatrics residency program. RESULTS. The response rate was 95%. Location was the most important factor in selecting a residency program for 42% of all residents. Almost half of the pediatrics residents planned to pursue fellowship training after residency, a proportion that changed little across the 3 training years (level 1: 47%; level 2: 49%; level 3: 47%). Those who planned to pursue a general pediatrics career (either with or without inpatient care) were more likely than those who intended to pursue fellowship training to report that lifestyle was the most important factor in their career choice (63% vs 21%). CONCLUSIONS. Not surprisingly, different priorities motivate pediatricians to pursue specific programs for training and specific career options. The finding that those with the highest priority regarding lifestyle are more likely to pursue generalist training has implications for the generalist workforce, because those persons may also be more likely to seek part-time employment. Lifestyle concerns may need to be addressed in subspecialty training and subsequent subspecialty careers to ensure a continued flow of residents into fellowship training.

The in-training examination: an analysis of its predictive value on performance on the general pediatrics certification examination.

OBJECTIVE This study investigates the predictive validity of the In-Training Examination (ITE). Although studies have confirmed the predictive validity of ITEs in other medical specialties, no study has been done for general pediatrics. STUDY DESIGN Each year, residents in accredited pediatric training programs take the ITE as a self-assessment instrument. The ITE is similar to the American Board of Pediatrics General Pediatrics Certifying Examination. First-time takers of the certifying examination over a 5-year period who took at least 1 ITE examination were included in the sample. Regression models analyzed the predictive value of the ITE. RESULTS The predictive power of the ITE in the first training year is minimal. However, the predictive power of the ITE increases each year, providing the greatest power in the third year of training. CONCLUSIONS Even though ITE scores provide information regarding the likelihood of passing the certification examination, the data should be used with caution, particularly in the first training year. Other factors also must be considered when predicting performance on the certification examination. This study continues to support the ITE as an assessment tool for program directors, as well as a means of providing residents with feedback regarding their acquisition of pediatric knowledge.

Controversy Surrounding the Use of Home Oxygen for Premature Infants with Bronchopulmonary Dysplasia

OBJECTIVE: To determine the criteria used in the current practice of neonatology for the initiation of home oxygen therapy in premature infants with bronchopulmonary dysplasia and to compare these criteria with the available literature regarding the use of home oxygen therapy.STUDY DESIGN: Participants in the December 2000 meeting of the Vermont Oxford Network were surveyed regarding their current use of home oxygen therapy for infants with bronchopulmonary dysplasia.RESULTS: Surveys were returned by 181 out of 297 participants. Pulse oximetry saturation (SpO2) thresholds for the initiation of home oxygen therapy varied widely from <84% to <98%. The most common threshold was <90% chosen by only 43% of the respondents. Additionally, 22% of the respondents did not initiate therapy until the oxygen saturation in room air was below 88%. Once on oxygen therapy, the target SpO2 also varied widely from >84% to >98%, with only 27% of respondents aiming for an SpO2 of >94%.CONCLUSIONS: There is a clear lack of consensus among neonatologists regarding the initiation of home oxygen therapy for bronchopulmonary dysplasia. Furthermore, the criteria used for home oxygen therapy varies widely with the majority of neonatologists surveyed using oxygen saturation levels not supported by the literature. We speculate that a significant underutilization of home oxygen therapy exists for infants with bronchopulmonary dysplasia.

Pediatric Fellows: Perspectives on Training and Future Scope of Practice

OBJECTIVE. Training for pediatric residents who intend to pursue fellowship differs little from training for residents who intend to practice general pediatrics. It is unknown how well residents who intend to pursue subspecialty training believe that residency prepares them for subspecialty fellowships or future careers. To characterize the strengths and weaknesses of residency training and the factors influencing subspecialty choice from the perspective of subspecialty fellows, we conducted a survey of current fellows on these issues. METHODS. A random sample of 1000 physicians who were entering their second or third year of fellowship in the United States in 2007 received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for fellowship, and plans for future practice. RESULTS. The overall response rate was 81%. A majority of the fellows would not have shortened their general pediatrics residency before fellowship if given the option (64% [n = 482]). However, more than half (52% [n = 390]) of the fellows would have chosen a 2-year fellowship without research or scholarly activity over the current 3-year structure. Few current fellows believed they could have used any additional training in the areas of patient safety, coordination of care for children with complex illnesses, or patient communication. CONCLUSIONS. The finding that a large proportion of fellows would opt for shortened subspecialty training should prompt discussion and debate within the profession regarding the skills necessary for a pediatric subspecialist. Patient safety, physician-parent communication, and care coordination are emphasized primarily through informal training during residency. Although most clinicians believe themselves to be adequately prepared, research has identified gaps in clinician skills and understanding of these issues of great importance to patients and their families.

Recently Trained Pediatric Subspecialists: Perspectives on Training and Scope of Practice

OBJECTIVES. Little is known regarding the factors influencing the decision to pursue pediatric subspecialty fellowship training and the timing of when such a decision is made. In addition, there is no information regarding whether the general pediatrics training received in residency is perceived as valuable by subspecialists. This study was conducted to characterize the strengths and weaknesses of residency and fellowship training from the perspective of recently trained pediatric subspecialists and to assess their current and future career goals and intended scope of practice. METHODS. A random sample of 550 subspecialists whose initial application for pediatric subspecialty certification occurred between 2002 and 2003 (4–5 years out of training) and 550 subspecialists who applied for board certification between 2005 and 2006 (1–2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for clinical care provision, and scope of current practice. RESULTS. The overall response rate was 77%. More than half (54%) of the recently trained subspecialists would have shortened either their pediatric residency or fellowship training if given the opportunity, and 7% were unsure. More than one third of the respondents made the decision to pursue subspecialty training before the start of residency (36% [n = 198]), whereas approximately half of them made this decision during the first (19% [n = 106]) or second (27% [n = 150]) year of residency. CONCLUSIONS. Many subspecialists would have been interested in modifications to their pediatric residency and fellowship training programs, which may reflect changing patterns of professional activities or the preferences of a younger generation of subspecialists. Given that a substantial proportion of subspecialists decide to pursue subspecialty training before or early in residency, greater flexibility in configuring some residency experiences to meet their career goals would be feasible.

Linking Process to Outcome: Are We Training Pediatricians to Meet Evolving Health Care Needs?

The Residency Review and Redesign in Pediatrics (R3P) Project began in 2005 and will have been completed in 2009. The purpose was to conduct a comprehensive reassessment of general pediatric residency education. The project convened 3 major colloquia supplemented by numerous meetings of an R3P committee and by surveys of residents, subspecialty fellows, and generalist and subspecialty practitioners. A principal conclusion was that resident learning opportunities should be more flexibly directed toward the variety of career choices available to pediatricians. Another conclusion was that reasonable expectations for residency education are most likely if learning is regarded as an integrated continuum, beginning in medical school and continuing throughout a career in practice. The R3P Committee declined to create a list of recommendations for immediate changes in residency education; instead, it recommends that changes be based on evidence of education outcomes that are important to improving the health of children, adolescents, and young adults.

Epidural anesthesia with bupivacaine for Cesarean section: neonatal blood levels and neurobehavioral responses.

: A recent study found no neurobehavioral change in infants whose mothers received bupivacaine epidural anesthesia (112 +/- 7 mg) for labor and vaginal delivery. The present study was undertaken to examine the possibility that the larger doses of bupivicaine necessary for cesarean section might cause neurobehavioral changes in the neonate. Ten infants delivered by cesarean section with bupivacaine epidural anesthesia (168 +/- 7 mg) was assessed by Scanlons neonatal neurobehavioral examination. They were compared in a prospective randomized study with a control group of ten infants delivered with tetracaine spinal anesthesia. In the experimental group bupivacaine was detectable in umbilical arterial blood (.17 +/- .07 microgram/ml), umbilical venous blood (.21 +/- .09 microgram/ml), and neonatal blood samples at 4 hours of age (.04 +/- .04 microgram/ml). By 24 hours of age bupivacaine was no longer detectable in newborn blood samples. Infants in the experimental group were indistinguishable from control infants in terms of their motor organization, responsiveness to external stimuli, and habituation to repetitive stimuli. Detectable neurobehavioral effects were absent despite the fact that 1.5 times the dose of bupivacaine used for labor and vaginal delivery was employed in this study.

Localized intestinal perforation following intravenous indomethacin for patent ductus arteriosus

We describe a very low birth weight infant given intravenous indomethacin for a symptomatic patent ductus arteriosus who subsequently developed a gastrointestinal perforation. Although this is a well-known complication of enteral preparations, it has not been described with the intravenous form. Various mechanisms described in the literature by which the intravenous route of administration may compromise the bowel are presented. Although rare, gastrointestinal complications with intravenous indomethacin may become more prevalent with its increased use.