Pediatric residency training: One size doesn't fit all

Thirty years ago, the report of the first Task Force on the Future of Pediatric Education* recommended that core pediatric residency training should extend for three years, and that training should be enhanced to ensure future pediatricians would be better prepared than their elders to address the "new morbidities" facing children and families in the US. Specifically, they recommended that training should address psychosocial, developmental, and ethical issues, and that health care needs of adolescents be explicitly included in pediatric residency training. In order to accomplish these goals, the Task Force recommended enhanced training and supervision in the ambulatory setting. Recognizing that these recommendations might run counter to service needs of the hospitals that fund residency education, the Task Force stated that "pediatric education can no longer be dependent upon antiquated in-hospital reimbursement mechanisms."

Thirty years later, some progress has been made in implementing the Task Force recommendations. The Pediatrics Residency Review Committee, which guides residency training through its accreditation process, moved quickly to make three years the standard duration of training. Experience in behavioral and developmental pediatrics and adolescent medicine are now required. The 2006 revision of the requirements state that training must take place in the ambulatory setting for at least 40% of the residency, with the number of months spent in the intensive care setting period restricted to no more than a total of six months.

While pediatric residency training has been changing, however, the gap between the health care that is provided and the health care needed by children in the US and around the world seems not to be closing. Pediatric residents perceive that gap, and many are frustrated that the experiences mandated by regulations will distract them from gaining the knowledge, skills, and experience they will need to help them address the needs they see.

The same flexibility would allow the pediatric resident planning a career in global health to enhance his/her training by including substantial international experiences during residency while forgoing some of the current requirements. Similarly, a resident planning a career in genetics and pediatrics probably doesn't need the same amount of time in intensive care or in the emergency department as the resident planning to be a pediatric hospitalist.

The barriers to more flexible and, arguably, more appropriate training are substantial. They include the mechanism by which residency training is funded, which remains unchanged after the first Task Force report; the difficulty designing and implementing individualized schedules while maintaining patient services; and the need to design assessments of competence to allow certification of physicians whose training is individualized.

Pediatric residents no longer see their career options as a choice between community-based general pediatrics and subspecialty fellowship training. They understand that the needs of children are more complicated than that. Some want careers as pediatricians who can coordinate a multidisciplinary approach to behavioral and developmental and medical needs; some want to be hospitalists; some, providers and designers of global health initiatives. The Residency Review and Redesign in Pediatrics project being coordinated by the American Board of Pediatrics is the most recent attempt to address pediatric residency training. If we're serious about training physicians who can best address all the varied needs of children, this effort will finally have to solve the problems posed in 1978 by the first Task Force on Pediatric Education.

*Task Force on Pediatric Education: The Future of Pediatric Education. Evanston, Ill., American Academy of Pediatrics, 1978.