Positive predictive value of medical student specialty choices.

BACKGROUND: Although medical school programs oriented toward postgraduate specialty training have the potential to reduce the duration and cost of medical school for US medical students, success depends on the ability of students to predict their postgraduate specialties. It is clear that first-year choices are poorly predictive, but it is not known when predictions become sufficiently reliable to support specialty-oriented learning programs. We therefore examined the predictive value of specialty preferences expressed at the ends of the first, second and third years of medical school and asked whether concurrent expressions of confidence in choices improved predictive ability. We also investigated the possibility that discrepancies between predicted and actual postgraduate specialty training were related to scores on an examination of knowledge in basic biomedical sciences required for US medical school graduation (the United States Medical Licensing Examination (USLME) Step 1 examination). METHOD: We calculated positive and negative predictive values (PPV and NPV, respectively) for specialty choices and the sensitivity and specificity of asking for choices for 634 University of Colorado School of Medicine students who trained in 23 accredited residencies from 2011 through 2015. We examined the effect of confidence in first choices in 609 students, and in 334 students, sought an association between USMLE Step 1 scores and switching from postgraduate training specialties predicted at the end of year 2. RESULTS: The PPV of first choices improved from years 1 through 3. NPV was high throughout. PPVs of year 3 first choices ranged from 79% in Anesthesiology to 95% in Psychiatry. Expressions of confidence in first choices did not improve PPV. Sensitivity of asking for first choices increased with time; specificity was consistently high. USLME Step 1 scores were higher for students who ultimately trained in specialties more competitive than first-choice specialties at the end of year 2. CONCLUSIONS: Specialty-oriented learning programs during medical school must accommodate students who change career plans. The PPV of specialty first choices improves each year, but even year 3 predictions can be inaccurate with potential loss of students from specialty-specific programs. USMLE Step 1 scores appeared to affect career plans expressed at the end of year 2.

Better Decision-Making: Shared Mental Models and the Clinical Competency Committee.

BACKGROUND: Shared mental models (SMMs) help groups make better decisions. Clinical competency committees (CCCs) can benefit from the development and use of SMMs in their decision-making as a way to optimize the quality and consistency of their decisions. OBJECTIVE: We reviewed the use of SMMs for decision making in graduate medical education, particularly their use in CCCs. METHODS: In May 2020, the authors conducted a narrative review of the literature related to SMMs. This review included the SMM related to teams, team functioning, CCCs, and graduate medical education. RESULTS: The literature identified the general use of SMMs, SMMs in graduate medical education, and strategies for building SMMs into the work of the CCC. Through the use of clear communication and guidelines, and a shared understanding of goals and expectations, CCCs can make better decisions. SMMs can be applied to Milestones, resident performance, assessment, and feedback. CONCLUSIONS: To ensure fair and robust decision-making, the CCC must develop and maintain SMMs through excellent communication and understanding of expectations among members.

An unusual cause of neonatal respiratory distress.

Nasal cysts representing cystic extension of the nasolacrimal duct are a rare cause of nasal obstruction and respiratory distress in neonates. A medial canthal mass, epiphora, dacryocystitis or preseptal/orbital cellulitis are the usual presenting symptoms; however, this case shows that patients may present with eye findings so minimal as to be overlooked.

Can we learn civility? Reflections on the challenge of changing culture.

Academic medicine shares the handicap of many hierarchical organizations in that it is difficult for those lower in the hierarchy to speak up when doing so requires challenging their chronologic and administrative elders. Elsewhere in this issue, Dankoski and colleagues offer specific recommendations for combating this "organizational silence," including training and mentorship for junior faculty. In this related Commentary, the authors cite their lack of success with isolated initiatives to address the problem of organizational silence in their own institution. They suggest that nothing short of a comprehensive, visible, high-priority organizational commitment to culture change is likely to be effective in facilitating respectful and candid communication up and down the academic hierarchy. Until the culture of academic medicine affirms that broad input is vital, learners and junior faculty are unlikely to feel safe in expressing concerns, providing feedback, reporting mistreatment or unprofessional behaviors, and offering suggestions for improvement.

A structured career-immersion experience in the third year of residency training.

This is the second in a series of 4 articles that highlight the projects that were chosen for implementation by the Initiative for Innovation in Pediatric Education (IIPE) review committee in response to the 2009 call for letters of intent. The authors describe their progress to date in implementing a training experience that allows residents the opportunity to engage in a longitudinal clinical experience that is aligned with their ultimate career choice. Mentors play a critical role in this immersion experience.

Training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study.

BACKGROUND: Resident training in pediatrics currently entails similar training for all residents in a fragmented curriculum with relatively little attention to the career plans of individual residents. OBJECTIVES: To explore strengths and gaps in training for residents planning a career in primary care pediatrics and to present strategies for addressing the gaps. METHODS: Surveys were sent to all graduates of the University of Colorado Denver Pediatric Residency Program (2003-2006) 3 years after completion of training. Respondents were asked to evaluate aspects of their training, using a 5-point Likert scale and evaluating each item ranging from "not at all well prepared" to "extremely well prepared" for their future career. In addition, focus groups were conducted with practitioners in 8 pediatric practices in Colorado. Sessions were transcribed and hand coded by 2 independent coders. RESULTS: Survey data identified training in behavior and development (mean score, 3.72), quality improvement and patient safety strategies (mean, 3.57), and practice management (mean, 2.46) as the weakest aspects of training. Focus groups identified deficiencies in training in mental health, practice management, behavioral medicine, and orthopedics. Deficiencies noted in curriculum structure were lack of residents' long-term continuity of relationships with patients; the need for additional training in knowledge, skills, and attitudes needed for primary care (perhaps even a fourth year of training); and a training structure that facilitates greater resident autonomy to foster development of clinical capability and self-confidence. CONCLUSIONS: Important gaps were identified in the primary care training of pediatric residents. These data support the need to develop more career-focused training.

Perspective: Competencies, outcomes, and controversy--linking professional activities to competencies to improve resident education and practice.

Regulatory organizations have recently emphasized the importance of structuring graduate medical education around mastery of core competencies. The difficulty is that core competencies attempt to distill a range of professional behaviors into arguable abstractions. As such, competencies can be difficult to grasp for trainees and faculty, who see them as unrelated to the intricacies of daily patient care. In this article, the authors describe how two initiatives are converging in a way that should make competencies tangible and relevant. One initiative is based on the idea that competencies will be more meaningful if trainees understand specifically how they relate to important professional activities in their own specialty. The authors suggest that there is a dyadic relationship between competencies and major professional activities in pediatric medicine. They also suggest that these relationships should be discussed as part of the process by which trainees are entrusted to perform clinical activities without direct supervision. The other initiative proposes to construct narrative milestones that provide a picture of what progression toward mastery of core competencies might look like. Together, the authors argue, these two initiatives should illuminate the core competencies by providing relevant clinical context and valuable educational substance.

Neonatal resuscitation skills among pediatricians and family physicians: is residency training preparing for postresidency practice?

BACKGROUND: Pediatricians and family physicians are responsible for providing newborn resuscitation, yet Accreditation Council for Graduate Medical Education requirements for training in this area during residency differ markedly for the two specialties. Our objectives were to determine (1) the extent to which neonatal resuscitation training differs for pediatric and family medicine residents; (2) the extent to which general pediatricians and family physicians engage in newborn resuscitation in their practice; and (3) whether use of resuscitation skills differs between urban/suburban and rural providers. METHODS: We surveyed a national cohort of pediatricians and family physicians who obtained board certification between 2001 and 2005. Data were analyzed based on type of physician and setting of current practice. RESULTS: Survey response rate was 22% (382 of 1736). Compared with family medicine physicians, pediatricians received more neonatal resuscitation training during residency. Most members of both groups had attended no deliveries in the year prior to the survey (75% [111 of 148] versus 74% [114 of 154]). In their current practice, the groups were equally likely to have provided a newborn bag and mask ventilation, chest compressions, and resuscitation medications. Pediatricians were more likely than family physicians to have attempted to either intubate a newborn (20% [28 of 148] versus 10% [16 of 153]; P  =  .0495) or insert umbilical catheters (15% [22 of 148] versus 5% [8 of 153]; P  =  .005). Regardless of specialty, rural physicians were much more likely to report that they attended deliveries (61% [41 of 67] versus 15% [36 of 234]; P < .001). Among rural pediatricians attending deliveries, 44% (7 of 16) reported feeling inadequately prepared for at least one delivery in the past year. CONCLUSIONS: Few primary care pediatricians and family physicians provide newborn resuscitation after residency. For those who do attend deliveries, current training 5 provide insufficient preparation. Flexible, individualized residency curricula could target intensive resuscitation training to individuals who plan to practice in rural areas and/or attend deliveries after graduation.

Longitudinal assessment of the timing of career choice among pediatric residents.

OBJECTIVE: To determine the timing of and key factors in resident decision making to pursue either a career in general pediatrics or subspecialty training. DESIGN: We used a 10-item fixed-choice questionnaire that focused on exploring how and when pediatric residents make career choices. SETTING: The survey was administered to all categorical pediatric residents in the United States and Canada as part of the General Pediatrics In-Training Examination in 2007 and 2009. The 2007 level 1 residents and 2009 level 3 residents were matched by a unique person identifier to create a longitudinal data set. PARTICIPANTS: A total of 2305 individuals completed the survey as level 1 residents in 2007 and level 3 residents in 2009, representing a retention rate of 83.5%. MAIN OUTCOME MEASURES: Change in individual and aggregate pediatric resident response over time. RESULTS: A similar number of individuals planned to pursue fellowship training in 2007 and 2009 (1026 vs 1062). Among this group, 745 (72.6%) of the 2009 residents were the same individuals who had indicated that they planned to pursue fellowship training in 2007. A total of 258 (71.9%) of all residents who reported in 2007 that they intended to pursue careers in general pediatrics with little or no inpatient care were still planning to do so in 2009. CONCLUSIONS: Most pediatricians make their decisions regarding pursuit of a career in primary care or to complete a fellowship before they ever enter residency training. It is unknown whether a similar timeline of decision making is consistent across specialties.

Looking to the future.

Participants of the Residency Review and Redesign (R(3)P) Project have created a challenging strategic plan for pediatric residency education. In place of a list of prescriptions for immediate change, the R(3)P Committee recommends an ongoing project of goal-directed change, a quality improvement approach to resident education. It argues for changes based on evidence of important education outcomes that improve the health of children, adolescents, and young adults. Creation and maintenance of a process of ongoing, adaptive change will depend on the combined efforts of the Association of Pediatric Program Directors, the Association of Medical School Department Chairs, the American Board of Pediatrics, the Resident Section of the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education Review Committee for Pediatrics.

Linking process to outcome: are we training pediatricians to meet evolving health care needs?

The Residency Review and Redesign in Pediatrics (R(3)P) 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 R(3)P 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 R(3)P 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.

The Residency Review and Redesign in Pediatrics (R3P) Project: roots and branches.

The Residency Review and Redesign in Pediatrics Project was fortunate to be able to take advantage of careful thinking by others. In addition to pediatricians, we sought advice from medical educators across the spectrum of medicine, especially in internal and family medicine. Participants in the project concluded early on that top-down "redesign" of pediatric resident education was neither realistic nor appropriate. A better and more durable alternative is a formal process by which residency education can learn and evolve over time. By committing to that model, pediatrics would finally carry out the mandate of the 1978 Task Force on Pediatric Education.

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.