Child-rearing During Postgraduate Medical Training and Its Relation to Stress and Burnout: Results From a Single-institution Multispecialty Survey.

INTRODUCTION: Child-rearing is difficult for medical trainees, but much of the available evidence is limited to individual specialties or lacks an analysis of well-being. In light of this, we sought to examine current perspectives across a wide range of medical specialties, determine associations with stress and burnout, and identify potential supportive solutions. METHODS: After Institutional Review Board approval, a voluntary and anonymous survey was sent to all residents and fellows at a large academic medical center with a U.S. Air Force joint training agreement in 2019. Frequency tables were generated for survey responses, using χ2 test for analysis between groups. RESULTS: One hundred and eighty-four physician trainees completed the survey (21.6% response rate), of which 38.0% were parents. Overall, 90.8% of trainees want children but 68.5% plan to wait until after training to start or grow their families, mainly due to insufficient time or inadequate child care. Less than 2% cited lack of program support as the reason. Among trainee parents, 72.0% reported that child care was at least quite stressful. Child care contributes to burnout for 68.6% of trainee parents, and there was no difference between medical and surgical trainees or between military and nonmilitary trainees. Day care was the most common primary child care strategy, and 37.1% of trainee parents reported spending >25% of their household income on child care. Proposed helpful solutions include on-site day care and subsidies. CONCLUSIONS: Most medical trainees in this sample want children, yet many are delaying growing their families due to time and financial constraints. For trainee parents, child care causes stress and family and financial strain and contributes to burnout. Physicians in training, including military members training at civilian medical centers, could benefit from child care assistance in order to relieve stress, reduce burnout, and improve well-being. Furthermore, by expanding existing resources and implementing new creative solutions to the challenges of child-rearing among medical professionals, the U.S. military has an opportunity to improve members' well-being and be a model to civilian graduate medical education programs nationwide.

Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown. OBJECTIVE: To determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate. METHODS: Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis. RESULTS: The response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21-2.71) and professionalization (2.37; 95% CI, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions. CONCLUSIONS: Most PDs have not established program minimum Milestones, but would vary such expectations according to competency.

Identifying Gaps in the Performance of Pediatric Trainees Who Receive Marginal/Unsatisfactory Ratings.

PURPOSE: To perform a derivation study to determine in which subcompetencies marginal/unsatisfactory pediatric residents had the greatest deficits compared with their satisfactorily performing peers and which subcompetencies best discriminated between marginal/unsatisfactory and satisfactorily performing residents. METHOD: Multi-institutional cohort study of all 21 milestones (rated on four or five levels) reported to the Accreditation Council for Graduate Medical Education, and global marginal/unsatisfactory versus satisfactory performance reported to the American Board of Pediatrics. Data were gathered in 2013-2014. For each level of training (postgraduate year [PGY] 1, 2, and 3), mean differences between milestone levels of residents with marginal/unsatisfactory and satisfactory performance adjusted for clustering by program and C-statistics (area under receiver operating characteristic curve) were calculated. A Bonferroni-corrected significance threshold of .0007963 was used to account for multiple comparisons. RESULTS: Milestone and overall performance evaluations for 1,704 pediatric residents in 41 programs were obtained. For PGY1s, two subcompetencies had almost a one-point difference in milestone levels between marginal/unsatisfactory and satisfactory trainees and outstanding discrimination (≥ 0.90): organize/prioritize (0.93; C-statistic: 0.91) and transfer of care (0.97; C-statistic: 0.90). The largest difference between marginal/unsatisfactory and satisfactory PGY2s was trustworthiness (0.78). The largest differences between marginal/unsatisfactory and satisfactory PGY3s were ethical behavior (1.17), incorporating feedback (1.03), and professionalization (0.96). For PGY2s and PGY3s, no subcompetencies had outstanding discrimination. CONCLUSIONS: Marginal/unsatisfactory pediatric residents had different subcompetency gaps at different training levels. While PGY1s may have global deficits, senior residents may have different performance deficiencies requiring individualized counseling and targeted performance improvement plans.

Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness.

PURPOSE: To describe clinical skills progression during pediatric residency using the distribution of pediatric milestone assessments by subcompetency and year of training and to determine reasonable milestone expectations at time of graduation. METHOD: Multi-institutional cohort study of the milestones reported to the Accreditation Council for Graduate Medical Education for all 21 pediatric subcompetencies. Most subcompetencies were measured using five milestone levels (1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, 5 = master); 3 subcompetencies had only four levels defined. RESULTS: Milestone assessments for 2,030 pediatric residents in 47 programs during academic year 2013-2014 were obtained. There was significant variation in end-of-year milestone ratings for residents within each level of training, which decreased as training level increased. Most (78.9%; 434/550) graduating third-year pediatric residents received a milestone rating of ≥ 3 in all 21 subcompetencies; fewer (21.1%; 116/550) received a rating of ≥ 4 in all subcompetencies. Across all training levels, professionalism and interpersonal communication skills were rated highest; quality improvement was rated lowest. CONCLUSIONS: Trainees entered residency with a wide range of skills. As they advanced, skill variability within a training level decreased. Most graduating pediatric residents were still advancing on the milestone continuum toward proficiency and mastery, and an expectation of milestone ratings ≥ 4 in all categories upon graduation is unrealistic; milestone ratings ≥ 3 upon graduation may be more realistic. Understanding current pediatric residents' and graduates' skills can help to identify key areas that should be specifically targeted during training.

Resident Self-Assessment and Learning Goal Development: Evaluation of Resident-Reported Competence and Future Goals.

OBJECTIVE: To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores. METHODS: Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression. RESULTS: A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s. CONCLUSIONS: Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency.

The pediatrics milestones: initial evidence for their use as learning road maps for residents.

OBJECTIVE: As the next step in competency-based medical education, the Pediatrics Milestone Project seeks to provide a learner-centered approach to training and assessment. To help accomplish this goal, this study sought to determine how pediatric residents understand, interpret, and respond to the Pediatrics Milestones. METHODS: Cognitive interviews with 48 pediatric residents from all training levels at 2 training programs were conducted. Each participant reviewed one Pediatrics Milestone document (PMD). Eight total Pediatrics Milestones, chosen for their range of complexity, length, competency domain, and primary author, were included in this study. Six residents, 2 from each year of residency training, reviewed each PMD. Interviews were transcribed and coded using inductive methods, and codes were grouped into themes that emerged. RESULTS: Four major themes emerged through coding and analysis: 1) the participants' degree of understanding of the PMDs is sufficient, often deep; 2) the etiology of participants' understanding is rooted in their experiences; 3) there are qualities of the PMD that may contribute to or detract from understanding; and 4) participants apply their understanding by noting the PMD describes a developmental progression that can provide a road map for learning. Additionally, we learned that residents are generally comfortable being placed in the middle of a series of developmental milestones. Two minor themes focusing on interest and practicality were also identified. CONCLUSIONS: This study provides initial evidence for the Pediatrics Milestones as learner-centered documents that can be used for orientation, education, formative feedback, and, ultimately, assessment.

Self-assessment on the competencies and reported improvement priorities for pediatrics residents.

BACKGROUND: Self-assessment and self-directed learning are essential to becoming an effective physician. OBJECTIVE: To identify factors associated with resident self-assessment on the competencies, and to determine whether residents chose areas of self-assessed relative weakness as areas for improvement in their Individualized Learning Plan (ILP). METHODS: We performed a cross-sectional analysis of the American Academy of Pediatrics' PediaLink ILP database. Pediatrics residents self-assessed their competency in the 6 Accreditation Council for Graduate Medical Education competencies using a color-coded slider scale with end anchors "novice" and "proficient" (0-100), and then chose at least 1 competency to improve. Multivariate regression explored the relationship between overall confidence in core competencies, sex, level of training, and degree (MD or DO) status. Correlation examined whether residents chose to improve competencies in which they rated themselves as lower. RESULTS: A total of 4167 residents completed an ILP in academic year 2009-2010, with residents' ratings improving from advanced beginner (48 on a 0-100 scale) in postgraduate year-1 residents (PGY-1s) to competent (75) in PGY-3s. Residents rated themselves as most competent in professionalism (mean, 75.3) and least competent in medical knowledge (mean, 55.8) and systems-based practice (mean, 55.2). In the adjusted regression model, residents' competency ratings increased by level of training and whether they were men. In PGY-3s, there was no difference between men and women. Residents selected areas for improvement that correlated to competencies where they had rated themselves lower (P < .01). CONCLUSION: Residents' self-assessment of their competencies increased by level of training, although residents rated themselves as least competent in medical knowledge and systems-based practice, even as PGY-3s. Residents tended to choose subcompetencies, which they rated as lower to focus on improving.

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

In December 2008, the Institute of Medicine published new recommendations regarding duty hours and supervision of residents' training in the United States. These recommendations evoked immediate concerns from program directors and leadership in all surgical and medical disciplines, including pediatrics. To address these concerns, the Accreditation Council for Graduate Medical Education convened a Duty Hours Congress in Chicago, Illinois, on June 11 and 12, 2009. This report summarizes the opinions and testimony of the organizations (American Academy of Pediatrics, Association of Pediatric Program Directors, and Council of Pediatric Specialties) that were invited to represent pediatrics at the Duty Hours Congress. The American Academy of Pediatrics, the Association of Pediatric Program Directors, and the Council of Pediatric Specialties supported the basic principles of the Institute of Medicine report regarding patient safety, resident supervision, resident safety, and the importance of effective "hand-offs"; however, the organizations opposed additional reductions in resident duty hours given the potential unintended adverse effects on the competency of trainees, the costs of graduate medical education, and the future pediatric workforce. These organizations agreed that additional changes in graduate medical education must be data driven and consider residents within the broader system of health care. The costs and benefits must be carefully analyzed before implementing the Institute of Medicine recommendations.

Pediatrics milestone project: next steps toward meaningful outcomes assessment.

In the September 2010 issue of JGME, the Pediatric Milestones Working Group published "The Pediatrics Milestones: Conceptual Framework, Guiding Principles, and Approach to Development", a document that describes the construction of the first iteration of the Pediatric Milestones. These Milestones were developed by the Working Group as a group of practical behavioral expectations for each of the 52 sub-competencies. In constructing these Milestones, the authors were cognizant of the need to ground the Milestones themselves in evidence, theories or other conceptual frameworks that would provide the basis for the ontogeny of development for each sub-competency. During this next phase of the Milestones development, the process will continue with consultation with content experts and consideration of assessment of Milestones. We have described possible measurement tools, explored threats to validity, establishment of benchmarks, and possible approaches to reporting of performance. The vision of the Pediatrics Milestone Project is to understand the development of a pediatrician from entry into medical school through the twilight of a physician's career, and the work will require a collaborative effort of the undergraduate and graduate medical education communities, and the accrediting and certifying bodies.

The pediatrics milestones: conceptual framework, guiding principles, and approach to development.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP) have partnered to initiate the Pediatrics Milestone Project to further refine the 6 ACGME competencies and to set performance standards as part of the continued commitment to document outcomes of training and program effectiveness. INTERVENTION: Members of the Pediatrics Milestone Project Working Group searched the medical literature and beyond to create a synopsis of models and evidence for a developmental ontogeny of the elements for 52 subcompetencies. For each subcompetency, we created a series of Milestones, grounded in the literature. The milestones were vetted with the entire working group, engaging in an iterative process of revisions until reaching consensus that their narrative descriptions (1) included all critical elements, (2) were behaviorally based, (3) were properly sequenced, and (4) represented the educational continuum of training and practice. OUTCOMES: We have completed the first iteration of milestones for all subcompetencies. For each milestone, a synopsis of relevant literature provides background, references, and a conceptual framework. These milestones provide narrative descriptions of behaviors that represent the ontogeny of knowledge, skill, and attitude development across the educational continuum of training and practice. DISCUSSION: The pediatrics milestones take us a step closer to meaningful outcome assessment. Next steps include undertaking rigorous study, making appropriate modifications, and setting performance standards. Our aim is to assist program directors in making more reliable and valid judgments as to whether a resident is a "good doctor" and to provide outcome evidence regarding the program's success in developing doctors.