Postgraduate Training in Ambulatory Pediatrics Program Evaluation Alvin H.
\s=b\
Novack, MD, Kenneth G. Reeb, MD
Ambulatory
pediatric,
adolescent
medicine, and child development fellowin the Ambulatory Pediatric Association (APA) newsletter were surveyed to gather information about the programs for prospective fellows, to develop a descriptive summary, and to determine the extent to which programs adhere to APA guidelines. Number and types of positions offered, criteria for admission to programs, program educational objectives and activities, and career choice of graduates were examined for the 73 programs offering 132 fellowship positions in 1976 to 1977. In general, APA guidelines were followed. Programs emphasized patient care experience in contrast to health care administration, research, and teaching. (Am J Dis Child 133:687-690, 1979)
ship programs listed
the 25 years, medical education has
graduate past During changed specialty (surgery, pediatrics,
from internal medicine, etc) or residency training to include subspecialty (fel¬
lowship) training. Despite the growth in numbers and types of fellowship From the Department of Pediatrics, Case Western Reserve University, and the Cleveland Metropolitan General Hospital (Dr Novack), and the Rainbow Babies' and Children's Hospital (Dr Reeb), Cleveland. Reprint requests to Department of Pediatrics, Cleveland Metropolitan General Hospital, 3395 Scranton Rd, Cleveland, OH 44109 (Dr Novack).
programs relatively, little available about the programs themselves or their trainees. Consid¬ erable attention has been focused on the educational objectives and activi¬ ties of general residency programs, but fellowship programs have not undergone this degree of scrutiny. In 1972, Mason1 reported the man¬ power needs of different specialties. He examined the physician-popula¬ tion ratio of specialties and subspecialties and compared existing ratios to the optimum ratios used by prepaid health plans to staff their programs. Specialists were not subclassified, and all internists and pediatricians were considered as primary care practition¬ ers. Thus, insight into numbers, type, and distribution of pediatrie and internal medicine primary care and subspecialist physicians was not dis¬ cernable from this study. Knowles2 also noted the scarcity of data about subspecialties and their related train¬ ing programs. Exceptions are recent reports assessing training programs and manpower needs in pediatrie cardiology and adolescent medi¬ cine.35 Finally, the Ambulatory Pediatrie Association (APA) investigated am¬
training data
are
bulatory pediatrie fellowship pro¬ grams in the United States and
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
Canada using questionnaire surveys of directors of fellowship programs wishing to list their programs in the association's special newsletter on fellowships. The results of the first survey
were
reported previously."
This report is an attempt to docu¬ ment the present efforts of the APA to assess training programs in ambu¬ latory pediatrics and the related areas of adolescent medicine and child development. The methodology used to gather the data may provide a model for other subspecialties. METHODOLOGY
Questionnaires
were distributed in No¬ vember 1975 to 212 pediatrie departmental chairmen and directors of programs pre¬ viously listed in the APA newsletter. Announcements of the planned listing were published in the APA newsletter. Directors of programs not previously listed in the APA newsletter either requested questionnaires in response to these an¬ nouncements or submitted completed ques¬ tionnaires obtained from the departmental chairmen. Programs not submitting a completed questionnaire were not included in the APA listing nor are they repre¬ sented in this report. Thus, the data contained in this report do not represent the universe of programs (a systematic survey of departmental chairmen to deter¬ mine the universe of programs was not attempted until 1978) but is concerned with
those programs that submitted
pleted questionnaire prior
to
a
com¬
February
1976. An exact determination of the repre¬ sentativeness of the sample of ambulatory pediatrie programs was not possible. There are no complete listings of ambulatory pediatrie fellowship programs. An attempt was made to compare the sample reported here with the fellowship listing in the Journal of Pediatrics. However, such a comparison was not possible because the latter listing uses different categories and includes second- and third-year residency training programs. This report probably under-represents adolescent fellowship programs since the Society for Adolescent Medicine reported on 28 adolescent programs training 46 fellows.4 Initial responses to the questionnaire were reviewed, and incomplete question¬ naires were returned with specific instruc¬ tions to allow for their completion. The goal of the survey was to determine the following: First, is general characteristics of ambulatory pediatrie, child develop¬ ment, and adolescent fellowship programs (for example, sponsoring institution, medi¬ cal school affiliation, number of positions offered, stipends, etc) listed in the APA newsletter. Second, is the criteria for acceptance of fellows to training programs. Third, is the educational objectives of fellowship programs. A rating scale, designed to reflect the reported relative emphasis placed on the educational objec¬ tives in each of the four content area categories (patient care, health care ad¬ ministration, research, and teaching) was developed. Respondents could report an emphasis on a five-point scale between zero (no emphasis) and four (extensive emphasis). The emphasis ratings for the educational objectives were determined by dividing the total number of points reported in a category by the total number of points possible. For example, the patient care category included seven objectives for a possible emphasis rating of 28 points. If 21 emphasis points were reported, the emphasis rating was 75.0 (21 divided by 28 x 100 75.0). Fourth, is the types of program activities and the time devoted to each. Information about program activities was elicited by presenting respondents with a list of activ¬ ities and asking them to indicate whether a -
particular activity was required, elective, or not offered. Respondents were also asked to estimate the time in hours/week allocated to each activity, but unfortunate¬ ly this latter question was not routinely
completed. Program activity emphasis was estimated by assigning scores of 1.0, 0.5,
0.0, respectively, tive, and not-offered and
to the required, elec¬ responses. Emphasis
ratings were calculated for each of the four activity areas (patient care, health care administration, research, and teaching) by dividing the numerical value of the responses in that area by the maximum possible score. For example, requiring three activities, offering one elective, and not offering a fifth of the five activities in the administration area received an em¬ phasis rating of 3 + 0.5 + 0/5 x 100 70.0. Fifth, is the APA guidelines include the following four categories: patient care, administration of health care, research, and teaching. The questionnaire was constructed to incorporate the guidelines in each of the four categories, and the data were examined to determine the degree to which the fellowship programs adhered to these guidelines. Sixth, is the posttraining careers of graduates. =
RESULTS
Seventy-three program directors submitted completed questionnaires. The programs were divided into the following three groups: adolescent
13, 17.8%), pediatrie ambulatory 53, 72.6%), and child develop¬ ment (N 7, 9.6%). Only five pro¬
(N (N
=
=
=
grams
with
a
not primarily associated university medical center. were
General Characteristics
One hundred and
ship positions programs during
were
thirty-two fellow¬ offered by the 73
the academic year 1976 to 1977. Thirteen adolescent programs offered 14 fellowship posi¬ tions; 53 ambulatory pediatrie pro¬ grams offered 102 fellowship posi¬ tions; and the seven child development programs offered 16 positions. During the academic year 1975 to 1976, 128 fellowship positions were filled. There are differences in the number of avail¬ able and filled positions when 1975 to 1976 and 1976 to 1977 data are compared. Adolescent programs of¬ fered fewer fellowship positions in 1976 to 1977 than were filled in 1975 to 1976. Ambulatory pediatrie and child development programs offered more positions during 1976 to 1977 than were filled in 1975 to 1976. Slightly less than half of the programs offer one year of training, whereas the majority offer two or more years of fellowship training. All
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
child
development programs are for two years, whereas the adolescent programs are equally divided between one-year and two-year programs. Program Criteria For Acceptance of Fellows Requirements for entry into the programs
types of
similar for all three programs. United States
were
citizenship (or Canadian citizenship for Canadian programs) was required by 31% of the programs. Half of the programs required that trainees be eligible for licensure to practice medi¬ cine, and only one fifth required state licensure. All programs required two or more years of previous pediatrie training. Educational
Objectives
The educational emphasis placed on each of the four categories (patient care, health care administration, re¬ search, and teaching) is represented by a score for that category (Table 1). A one-way analysis of variance was used to analyze the data.7 There were no statistical differences among pro¬ gram types for all four categories. Statistical comparison of the empha¬ sis rating among categories was not possible, but all three program types seemed to place greater emphasis on patient care educational objectives and similar emphasis on the other three categories with only minor vari¬ ations among program types. Program activity and educational objective data were analyzed similarly (Table 2). There was a statistical difference among program types for patient care activities, and there seemed to be less emphasis on teach¬ ing activities for all program types. The differences among program types for the other categories were not statistically different. Patient Care
The size of the patient assigned to fellows for care
experiences
was
population continuing surveyed. Al¬
most 80% of the adolescent programs required trainees to follow 100 or
fewer patients, whereas one fifth of the programs require their fellows to follow 100 to 300 patients. Examina¬ tion of ambulatory pediatrie programs
Table 1 .—Educational Patient Program Type Care, mean Adolescent (N 77.5 13) Ambulatory pediatrics 74.9 (N 53) Child development 79.5 (N 7) 75.8 Total (N 73)
Research,
Teaching,
mean
mean
55
58
29
611
57
35
Research Activities
70
74
50
61
59
36
Health Care
Research,
Teaching,
mean
mean
53.6
55.4*
65.3*
58.2
55.9
58.3*
63.8
63.6 55.6
60.1" 59.6
Administration,
=
=
=
mean
57.9
=
*N
low for all three program types. A correlation matrix showed a high posi¬ tive correlation between administra¬ tive (0.617) and research (0.648) educa¬ tional objectives and activities. There was less correlation for educational objectives and activities for teaching (0.302) especially for group instruction (lay education, 0.300), and almost no correlation for patient care (0.114). The lack of correlation between patient care educational objectives and activities can be attributed to the child development and to a lesser extent the adolescent programs.
Objectives by Program Type
1 for these cells.
=
—
Table
2.—Program Activities by Program Type
Patient* Program Type Care, mean Adolescent (N 77 13) Ambulatory pediatrics 83 (N 53) Child development 62 (N 7) 79.6 Total (N 73)
Health Care
Administration,
=
=
=
=
*P
=
tN
=
.05; F
=
mean
Research activities were subdivided into traditional and nontraditional categories. The nontraditional catego¬ ry included areas of investigation that could be broadly categorized as health services research. The traditional cat¬ egory included what is generally considered clinical research. When the three program types were compared, they were significantly different with adolescent programs having lower scores (0.17 ± 0.17) than child devel¬
5.36.
1 for this cell. -
Table 3.—Careers of Graduates Trained in Past Five Years
Ambulatory
Careers of Graduates Armed services Private practice of pediat¬ rics
Outpatient department of university hospitals Outpatient department of other hospitals Comprehensive care pro¬
grams in poor commu¬ nities Full-time medical care re¬ search Other Still In training or Incom¬ plete data reported
showed that 38%
by Program Type
Child
Adolescent (N = 95), % 7.4
Pediatrics (N = 225), % 4.0
Development (N = 45), %
22.1
30.8
42.2
29.9
32.6
21.4
6.7
22.5
3.2
10.3
3.2
15.6
2.2
10.7
Total
(N
=
364), % 4.4
opment (0.30 ± 0.15) or ambulatory (0.40 ± 0.18) for nontraditional re¬ search activities (P < .05). Careers
11.6 15.8
4.5 3.6
178
6.9 8.5
4.1
9.8
17.8
9.4
require fellows
to
for 100 to 300 provide continuing patients. Child development fellow¬ ship programs differed considerably from adolescent and pediatrie ambula¬ tory programs requiring continuous care experiences for fewer patients. Many programs (approximately two thirds) require fellows to take some night call. Adolescent programs aver¬ age two nights on call per week; ambulatory pediatrie programs and child development programs average one night of call per week. care
Adherence to Guidelines
In general, the programs adhered to the APA guidelines for pediatrie ambulatory fellowships. It seems
8.9
There have been 95 adolescent, 224
ambulatory pediatrics, and 45 child development fellows trained by the 73 programs during the five years prior to the survey. The
teaching and to a lesser extent health care
administration and research
are
given less emphasis than suggested by the guidelines. The determination of substantial deficiencies in these areas was not within the scope of this
study.
As noted previously, scores were computed both for program educa¬ tional objectives and activities. The data were analyzed to determine the relationship between educational ob¬ jectives and program activities for each of the four categories and the three program types. In general, program activities and objectives were similar. The emphasis placed on the activity of teaching both lay and professional groups was quite
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
career patterns of these 364 graduates are shown in Table 3. Thirty percent of all fellows are engaged in the private practice of pediatrics, and 22.5% are employed by outpatient departments of university hospitals; almost 11% are actively-
in comprehensive care pro¬ in grams poor communities, and 6.9% are involved in some medical care research in an academic environ¬
engaged
ment.
Graduates of adolescent training are more often employed in outpatient departments of university hospitals, and almost 12% are em¬ ployed by an academic institution and do some medical care research. Very few graduates are employed by outpa¬ tient departments of hospitals other than university hospitals or in comprograms
prehensive care programs for poor people. Twenty-two percent of the graduates of adolescent programs are engaged in the private practice of pediatrics. Graduates of pediatrie am¬ bulatory programs, on the other hand, are more often engaged in private practice, outpatient departments, and comprehensive care programs, where¬ as only 4.5% are in full-time medical care
research. Almost half of the child fellows are in private 18% are in a variety of
development practice, and
programs not
easily categorized.
COMMENT
This survey and its predecessor, have been useful in providing infor¬ mation about the nature of fellowship training programs in ambulatory pe¬ diatrics and the related areas of adolescent medicine and child devel¬ opment. Information has been ob¬ tained concerning characteristics of trainees, the orientation and nature of the education programs, and the even¬ tual careers of program graduates. This information has been dissemi¬ nated to members of the APA and has been used by program directors and others planning programs as well as prospective trainees interested in information about specific programs. The data have been helpful to the leadership of the APA, which is inter¬ ested in monitoring the quality and quantity of ambulatory fellowship training in the interest of upgrading the quality of programs.
The established guidelines of the APA provide a useful standard against which programs can be com¬ pared. At this time, we have no meth¬ od for validating the accuracy of the information obtained through the mechanism of self-reporting by pro¬ gram directors. We surmise that the degree of reliability differs with the information requested. For instance, the accuracy of information obtained by questionnaires about educational objectives should compare favorably with other data-gathering methods. On the other hand, information about the careers of graduates might better be obtained by surveying the grad¬ uates directly. Information about time devoted to different activities would probably be best obtained by direct observation. The inability to determine the universe of graduate training pro¬ grams in the three areas (child devel¬ opment, adolescent medicine, and pe¬ diatrie ambulatory) represents a con¬ straint in making any generalizations from these data. The programs re¬ sponding to the survey represent a biased sample since programs more closely adhering to APA guidelines were more likely to respond. In the future, an attempt will be made to develop a listing of all fellowship programs providing training in ambu¬ latory pediatrics, child development, and adolescent medicine. This will be
accomplished by surveying pediatrie departmental chairmen.
Our intent is to continue to explore the value of the present method of
monitoring ambulatory fellowship programs. An effort will be made to
validate future questionnaires with selected on-site observations. Based on our finding that little information about fellowship training is available, we recommend that other pediatrie subspecialties develop a unified re¬ porting system to evaluate programs and trainees. A necessary first step is a willingness on the part of the pedi¬ atrie subspecialties to gather data about their training programs and trainees. If such were the case, devel¬ opment of a unified reporting system could be achieved. The project was supported in part by the Ambulatory Pediatrie Association. Margaret C. Heagarty, MD, and Robert A. Hoekelman, MD, helped in the preparation of this manuscript. Judith Lovecchio and Barbara McVicker also assisted in this project.
References 1. Mason HR: Manpower needs by specialty. JAMA 219:1621-1626, 1972. 2. Knowles JH: The quantity and quality of medical manpower: A review of medicine's current efforts. J Med Educ 44:81-118, 1969. 3. Adams FH, Blumenthal S, DuShane JW, et al: Manpower and training requirements in pediatric cardiology. Pediatrics 51:813, 1975. 4. Hofmann AD: Fellowships in adolescent medicine. Soc Adolescent Med Newsletter 8:2-31, 1972. 5. Hofmann AD: Fellowships in adolescent medicine. J Pediatr 83:512-514, 1973. 6. Heagarty MC, Fischbarg S: Ambulatory pediatric fellowship programs. Am J Dis Child 129:29-31, 1975. 7. Rahn AK: Bowie Medical Statistics, New York, Greene and Stratton, 1972, pp 178-180.
CORRECTION Error in Last Entry in Subjects Column in Table.\p=n-\Inthe article titled "RBC Surface Pits in the Sickle Hemoglobinopathies," published in the May Journal (133:526-527,1979), an error occurred in the final entry in the "Subjects" column in the Table. It should read "Hemoglobin S-C disease" and not "Sickle cell disease."
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
\s=b\
Novack, MD, Kenneth G. Reeb, MD
Ambulatory
pediatric,
adolescent
medicine, and child development fellowin the Ambulatory Pediatric Association (APA) newsletter were surveyed to gather information about the programs for prospective fellows, to develop a descriptive summary, and to determine the extent to which programs adhere to APA guidelines. Number and types of positions offered, criteria for admission to programs, program educational objectives and activities, and career choice of graduates were examined for the 73 programs offering 132 fellowship positions in 1976 to 1977. In general, APA guidelines were followed. Programs emphasized patient care experience in contrast to health care administration, research, and teaching. (Am J Dis Child 133:687-690, 1979)
ship programs listed
the 25 years, medical education has
graduate past During changed specialty (surgery, pediatrics,
from internal medicine, etc) or residency training to include subspecialty (fel¬
lowship) training. Despite the growth in numbers and types of fellowship From the Department of Pediatrics, Case Western Reserve University, and the Cleveland Metropolitan General Hospital (Dr Novack), and the Rainbow Babies' and Children's Hospital (Dr Reeb), Cleveland. Reprint requests to Department of Pediatrics, Cleveland Metropolitan General Hospital, 3395 Scranton Rd, Cleveland, OH 44109 (Dr Novack).
programs relatively, little available about the programs themselves or their trainees. Consid¬ erable attention has been focused on the educational objectives and activi¬ ties of general residency programs, but fellowship programs have not undergone this degree of scrutiny. In 1972, Mason1 reported the man¬ power needs of different specialties. He examined the physician-popula¬ tion ratio of specialties and subspecialties and compared existing ratios to the optimum ratios used by prepaid health plans to staff their programs. Specialists were not subclassified, and all internists and pediatricians were considered as primary care practition¬ ers. Thus, insight into numbers, type, and distribution of pediatrie and internal medicine primary care and subspecialist physicians was not dis¬ cernable from this study. Knowles2 also noted the scarcity of data about subspecialties and their related train¬ ing programs. Exceptions are recent reports assessing training programs and manpower needs in pediatrie cardiology and adolescent medi¬ cine.35 Finally, the Ambulatory Pediatrie Association (APA) investigated am¬
training data
are
bulatory pediatrie fellowship pro¬ grams in the United States and
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
Canada using questionnaire surveys of directors of fellowship programs wishing to list their programs in the association's special newsletter on fellowships. The results of the first survey
were
reported previously."
This report is an attempt to docu¬ ment the present efforts of the APA to assess training programs in ambu¬ latory pediatrics and the related areas of adolescent medicine and child development. The methodology used to gather the data may provide a model for other subspecialties. METHODOLOGY
Questionnaires
were distributed in No¬ vember 1975 to 212 pediatrie departmental chairmen and directors of programs pre¬ viously listed in the APA newsletter. Announcements of the planned listing were published in the APA newsletter. Directors of programs not previously listed in the APA newsletter either requested questionnaires in response to these an¬ nouncements or submitted completed ques¬ tionnaires obtained from the departmental chairmen. Programs not submitting a completed questionnaire were not included in the APA listing nor are they repre¬ sented in this report. Thus, the data contained in this report do not represent the universe of programs (a systematic survey of departmental chairmen to deter¬ mine the universe of programs was not attempted until 1978) but is concerned with
those programs that submitted
pleted questionnaire prior
to
a
com¬
February
1976. An exact determination of the repre¬ sentativeness of the sample of ambulatory pediatrie programs was not possible. There are no complete listings of ambulatory pediatrie fellowship programs. An attempt was made to compare the sample reported here with the fellowship listing in the Journal of Pediatrics. However, such a comparison was not possible because the latter listing uses different categories and includes second- and third-year residency training programs. This report probably under-represents adolescent fellowship programs since the Society for Adolescent Medicine reported on 28 adolescent programs training 46 fellows.4 Initial responses to the questionnaire were reviewed, and incomplete question¬ naires were returned with specific instruc¬ tions to allow for their completion. The goal of the survey was to determine the following: First, is general characteristics of ambulatory pediatrie, child develop¬ ment, and adolescent fellowship programs (for example, sponsoring institution, medi¬ cal school affiliation, number of positions offered, stipends, etc) listed in the APA newsletter. Second, is the criteria for acceptance of fellows to training programs. Third, is the educational objectives of fellowship programs. A rating scale, designed to reflect the reported relative emphasis placed on the educational objec¬ tives in each of the four content area categories (patient care, health care ad¬ ministration, research, and teaching) was developed. Respondents could report an emphasis on a five-point scale between zero (no emphasis) and four (extensive emphasis). The emphasis ratings for the educational objectives were determined by dividing the total number of points reported in a category by the total number of points possible. For example, the patient care category included seven objectives for a possible emphasis rating of 28 points. If 21 emphasis points were reported, the emphasis rating was 75.0 (21 divided by 28 x 100 75.0). Fourth, is the types of program activities and the time devoted to each. Information about program activities was elicited by presenting respondents with a list of activ¬ ities and asking them to indicate whether a -
particular activity was required, elective, or not offered. Respondents were also asked to estimate the time in hours/week allocated to each activity, but unfortunate¬ ly this latter question was not routinely
completed. Program activity emphasis was estimated by assigning scores of 1.0, 0.5,
0.0, respectively, tive, and not-offered and
to the required, elec¬ responses. Emphasis
ratings were calculated for each of the four activity areas (patient care, health care administration, research, and teaching) by dividing the numerical value of the responses in that area by the maximum possible score. For example, requiring three activities, offering one elective, and not offering a fifth of the five activities in the administration area received an em¬ phasis rating of 3 + 0.5 + 0/5 x 100 70.0. Fifth, is the APA guidelines include the following four categories: patient care, administration of health care, research, and teaching. The questionnaire was constructed to incorporate the guidelines in each of the four categories, and the data were examined to determine the degree to which the fellowship programs adhered to these guidelines. Sixth, is the posttraining careers of graduates. =
RESULTS
Seventy-three program directors submitted completed questionnaires. The programs were divided into the following three groups: adolescent
13, 17.8%), pediatrie ambulatory 53, 72.6%), and child develop¬ ment (N 7, 9.6%). Only five pro¬
(N (N
=
=
=
grams
with
a
not primarily associated university medical center. were
General Characteristics
One hundred and
ship positions programs during
were
thirty-two fellow¬ offered by the 73
the academic year 1976 to 1977. Thirteen adolescent programs offered 14 fellowship posi¬ tions; 53 ambulatory pediatrie pro¬ grams offered 102 fellowship posi¬ tions; and the seven child development programs offered 16 positions. During the academic year 1975 to 1976, 128 fellowship positions were filled. There are differences in the number of avail¬ able and filled positions when 1975 to 1976 and 1976 to 1977 data are compared. Adolescent programs of¬ fered fewer fellowship positions in 1976 to 1977 than were filled in 1975 to 1976. Ambulatory pediatrie and child development programs offered more positions during 1976 to 1977 than were filled in 1975 to 1976. Slightly less than half of the programs offer one year of training, whereas the majority offer two or more years of fellowship training. All
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
child
development programs are for two years, whereas the adolescent programs are equally divided between one-year and two-year programs. Program Criteria For Acceptance of Fellows Requirements for entry into the programs
types of
similar for all three programs. United States
were
citizenship (or Canadian citizenship for Canadian programs) was required by 31% of the programs. Half of the programs required that trainees be eligible for licensure to practice medi¬ cine, and only one fifth required state licensure. All programs required two or more years of previous pediatrie training. Educational
Objectives
The educational emphasis placed on each of the four categories (patient care, health care administration, re¬ search, and teaching) is represented by a score for that category (Table 1). A one-way analysis of variance was used to analyze the data.7 There were no statistical differences among pro¬ gram types for all four categories. Statistical comparison of the empha¬ sis rating among categories was not possible, but all three program types seemed to place greater emphasis on patient care educational objectives and similar emphasis on the other three categories with only minor vari¬ ations among program types. Program activity and educational objective data were analyzed similarly (Table 2). There was a statistical difference among program types for patient care activities, and there seemed to be less emphasis on teach¬ ing activities for all program types. The differences among program types for the other categories were not statistically different. Patient Care
The size of the patient assigned to fellows for care
experiences
was
population continuing surveyed. Al¬
most 80% of the adolescent programs required trainees to follow 100 or
fewer patients, whereas one fifth of the programs require their fellows to follow 100 to 300 patients. Examina¬ tion of ambulatory pediatrie programs
Table 1 .—Educational Patient Program Type Care, mean Adolescent (N 77.5 13) Ambulatory pediatrics 74.9 (N 53) Child development 79.5 (N 7) 75.8 Total (N 73)
Research,
Teaching,
mean
mean
55
58
29
611
57
35
Research Activities
70
74
50
61
59
36
Health Care
Research,
Teaching,
mean
mean
53.6
55.4*
65.3*
58.2
55.9
58.3*
63.8
63.6 55.6
60.1" 59.6
Administration,
=
=
=
mean
57.9
=
*N
low for all three program types. A correlation matrix showed a high posi¬ tive correlation between administra¬ tive (0.617) and research (0.648) educa¬ tional objectives and activities. There was less correlation for educational objectives and activities for teaching (0.302) especially for group instruction (lay education, 0.300), and almost no correlation for patient care (0.114). The lack of correlation between patient care educational objectives and activities can be attributed to the child development and to a lesser extent the adolescent programs.
Objectives by Program Type
1 for these cells.
=
—
Table
2.—Program Activities by Program Type
Patient* Program Type Care, mean Adolescent (N 77 13) Ambulatory pediatrics 83 (N 53) Child development 62 (N 7) 79.6 Total (N 73)
Health Care
Administration,
=
=
=
=
*P
=
tN
=
.05; F
=
mean
Research activities were subdivided into traditional and nontraditional categories. The nontraditional catego¬ ry included areas of investigation that could be broadly categorized as health services research. The traditional cat¬ egory included what is generally considered clinical research. When the three program types were compared, they were significantly different with adolescent programs having lower scores (0.17 ± 0.17) than child devel¬
5.36.
1 for this cell. -
Table 3.—Careers of Graduates Trained in Past Five Years
Ambulatory
Careers of Graduates Armed services Private practice of pediat¬ rics
Outpatient department of university hospitals Outpatient department of other hospitals Comprehensive care pro¬
grams in poor commu¬ nities Full-time medical care re¬ search Other Still In training or Incom¬ plete data reported
showed that 38%
by Program Type
Child
Adolescent (N = 95), % 7.4
Pediatrics (N = 225), % 4.0
Development (N = 45), %
22.1
30.8
42.2
29.9
32.6
21.4
6.7
22.5
3.2
10.3
3.2
15.6
2.2
10.7
Total
(N
=
364), % 4.4
opment (0.30 ± 0.15) or ambulatory (0.40 ± 0.18) for nontraditional re¬ search activities (P < .05). Careers
11.6 15.8
4.5 3.6
178
6.9 8.5
4.1
9.8
17.8
9.4
require fellows
to
for 100 to 300 provide continuing patients. Child development fellow¬ ship programs differed considerably from adolescent and pediatrie ambula¬ tory programs requiring continuous care experiences for fewer patients. Many programs (approximately two thirds) require fellows to take some night call. Adolescent programs aver¬ age two nights on call per week; ambulatory pediatrie programs and child development programs average one night of call per week. care
Adherence to Guidelines
In general, the programs adhered to the APA guidelines for pediatrie ambulatory fellowships. It seems
8.9
There have been 95 adolescent, 224
ambulatory pediatrics, and 45 child development fellows trained by the 73 programs during the five years prior to the survey. The
teaching and to a lesser extent health care
administration and research
are
given less emphasis than suggested by the guidelines. The determination of substantial deficiencies in these areas was not within the scope of this
study.
As noted previously, scores were computed both for program educa¬ tional objectives and activities. The data were analyzed to determine the relationship between educational ob¬ jectives and program activities for each of the four categories and the three program types. In general, program activities and objectives were similar. The emphasis placed on the activity of teaching both lay and professional groups was quite
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
career patterns of these 364 graduates are shown in Table 3. Thirty percent of all fellows are engaged in the private practice of pediatrics, and 22.5% are employed by outpatient departments of university hospitals; almost 11% are actively-
in comprehensive care pro¬ in grams poor communities, and 6.9% are involved in some medical care research in an academic environ¬
engaged
ment.
Graduates of adolescent training are more often employed in outpatient departments of university hospitals, and almost 12% are em¬ ployed by an academic institution and do some medical care research. Very few graduates are employed by outpa¬ tient departments of hospitals other than university hospitals or in comprograms
prehensive care programs for poor people. Twenty-two percent of the graduates of adolescent programs are engaged in the private practice of pediatrics. Graduates of pediatrie am¬ bulatory programs, on the other hand, are more often engaged in private practice, outpatient departments, and comprehensive care programs, where¬ as only 4.5% are in full-time medical care
research. Almost half of the child fellows are in private 18% are in a variety of
development practice, and
programs not
easily categorized.
COMMENT
This survey and its predecessor, have been useful in providing infor¬ mation about the nature of fellowship training programs in ambulatory pe¬ diatrics and the related areas of adolescent medicine and child devel¬ opment. Information has been ob¬ tained concerning characteristics of trainees, the orientation and nature of the education programs, and the even¬ tual careers of program graduates. This information has been dissemi¬ nated to members of the APA and has been used by program directors and others planning programs as well as prospective trainees interested in information about specific programs. The data have been helpful to the leadership of the APA, which is inter¬ ested in monitoring the quality and quantity of ambulatory fellowship training in the interest of upgrading the quality of programs.
The established guidelines of the APA provide a useful standard against which programs can be com¬ pared. At this time, we have no meth¬ od for validating the accuracy of the information obtained through the mechanism of self-reporting by pro¬ gram directors. We surmise that the degree of reliability differs with the information requested. For instance, the accuracy of information obtained by questionnaires about educational objectives should compare favorably with other data-gathering methods. On the other hand, information about the careers of graduates might better be obtained by surveying the grad¬ uates directly. Information about time devoted to different activities would probably be best obtained by direct observation. The inability to determine the universe of graduate training pro¬ grams in the three areas (child devel¬ opment, adolescent medicine, and pe¬ diatrie ambulatory) represents a con¬ straint in making any generalizations from these data. The programs re¬ sponding to the survey represent a biased sample since programs more closely adhering to APA guidelines were more likely to respond. In the future, an attempt will be made to develop a listing of all fellowship programs providing training in ambu¬ latory pediatrics, child development, and adolescent medicine. This will be
accomplished by surveying pediatrie departmental chairmen.
Our intent is to continue to explore the value of the present method of
monitoring ambulatory fellowship programs. An effort will be made to
validate future questionnaires with selected on-site observations. Based on our finding that little information about fellowship training is available, we recommend that other pediatrie subspecialties develop a unified re¬ porting system to evaluate programs and trainees. A necessary first step is a willingness on the part of the pedi¬ atrie subspecialties to gather data about their training programs and trainees. If such were the case, devel¬ opment of a unified reporting system could be achieved. The project was supported in part by the Ambulatory Pediatrie Association. Margaret C. Heagarty, MD, and Robert A. Hoekelman, MD, helped in the preparation of this manuscript. Judith Lovecchio and Barbara McVicker also assisted in this project.
References 1. Mason HR: Manpower needs by specialty. JAMA 219:1621-1626, 1972. 2. Knowles JH: The quantity and quality of medical manpower: A review of medicine's current efforts. J Med Educ 44:81-118, 1969. 3. Adams FH, Blumenthal S, DuShane JW, et al: Manpower and training requirements in pediatric cardiology. Pediatrics 51:813, 1975. 4. Hofmann AD: Fellowships in adolescent medicine. Soc Adolescent Med Newsletter 8:2-31, 1972. 5. Hofmann AD: Fellowships in adolescent medicine. J Pediatr 83:512-514, 1973. 6. Heagarty MC, Fischbarg S: Ambulatory pediatric fellowship programs. Am J Dis Child 129:29-31, 1975. 7. Rahn AK: Bowie Medical Statistics, New York, Greene and Stratton, 1972, pp 178-180.
CORRECTION Error in Last Entry in Subjects Column in Table.\p=n-\Inthe article titled "RBC Surface Pits in the Sickle Hemoglobinopathies," published in the May Journal (133:526-527,1979), an error occurred in the final entry in the "Subjects" column in the Table. It should read "Hemoglobin S-C disease" and not "Sickle cell disease."
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
