Your residents can achieve competency in pediatrics Scott Krugman, MD, MS Suki Tepperberg, MD Harsha Bhagtani, MD

Agenda Welcome Introductions Data on current status of pediatrics in FM residencies Curriculum guidelines Incorporating curricula into reality

Rationale for Excellence in FM resident training in Pediatrics Family physicians spend about 10% of their total practice time caring for children Consider rural communities- FP provide medical home for 1/3 of US children 68% of FP report caring for children, down from 78% in 2000 Phillips RL Jr, Bazemore AW, Dodoo MS, Shipman SA, Green LA. Pediatrics. 2006 Sep;118(3):1200-6. Review

Decrease in care of children Why? Not clear… Increasing number of pediatricians? Decreasing OB care provided by FM? Increased geriatric patients? Low Medicaid reimbursements? Implications for rural and underserved communities if FPs are not adequately trained Decreased overall numbers may result in diluted experience and training challenges Bazemore AW, Makaroff LA, Puffer JC, Parhat P, Phillips RL, Xierali IM, Rinaldo J. J Am Board Fam Med. 2012 Mar-Apr;25(2):139-40.

Key questions What are the pediatric competencies FM residents need to learn? What is the best way to teach these competencies? How do you best evaluate acquisition of the competencies?

Status of pediatrics in FM programs (2009)

Demographics 115 programs 88 stand alone without peds residency 76 community based university affiliated 15 community based not university affiliated 15 university based 8 community based, university administered 88 stand alone without peds residency 44 have rotations at University or Children’s Hospital

Time on pediatrics Total: Dedicated Pediatric Inpatient: Mean 4.3, Median 4 months, range 1-7 9% under 4 months, 53% 4 months, 24% 5 months, 5% more than 5 months Dedicated Pediatric Inpatient: Median 3, range 0-6 23% 2 months, 21% 3 months, 21% 4 months

Time on pediatrics Combo inpatient: PED: Outpatient: Median 6 months, range 0-36 25-75 IQR 4-6 months PED: Mean 0.5, median 0, range 0-2 months Outpatient: Mean 1.3, median 1, range 0-5.5 months

Family Health Center Number of pediatric patients Teachers: Mean 24% Median 25% Range 5-50% (25-75 IQR 20-30%) Teachers: 18% of programs have a pediatrician in the FHC

Prior data – Gauthier 2006

Child Health Training Time Mean=4.7 months

Child Health Training Settings Percent reporting Average time (range) in months General inpatient 96 1.8 (0-6.7) General specific outpatient 94 (0-5.4) Newborn (normal nursery or NICU) 1 (0-5.2)

Conclusions Total time continues to fall: 5.2 to 4.7 to 4.3 Total outpatient time lower: 1.8 to 1.3 Despite changing demographics, very few programs have PED rotations Teaching in FHC varies widely – who and percent of kids

Curriculum development Joint venture between STFM Care of Children Group and APA Pediatrics for Family Practice SIG Multi-year effort Published on APA website: http://www.ambpeds.org/education/education_Curricula.cfm

Curriculum incorporation Handouts one example of how

Prior RRC requirements IV.A.5.b).(2) Care of Neonates, Infants, Children, and Adolescents must complete four months of structured experience in the care of infants, children and adolescents. IV.A.5.b).(2).(a) The time must include experience in the following areas: neonates, infant care (both well-baby and ill), hospitalized children, ambulatory pediatrics, emergency care of children and adolescent medicine. This may include experience gained on the Family Medicine Inpatient Service, in the emergency department, in the pediatric hospital and clinic, and experience in nursery care associated with OB experience, provided that appropriate documentation of such experience is maintained for each resident. IV.A.5.b).(2).(b) This experience must involve teaching and role modeling by family medicine faculty in the care of newborns and sick children. Residents and faculty must provide continuity of responsibility for hospitalized infants and children from their Family Medicine Center patient panel.

Current/proposed RRC guidelines IV.A.6.a).(4).(b) Ten percent of the FMP patient encounters must be  with patients younger than 10 years of age.    IV.A.6.e) Residents must have at least 200 hours or two months and 250 patient encounters dedicated to the care of ill child patients in the hospital and/or emergency setting. (Core) IV.A.6.e).(1) This experience should include a minimum of 75 inpatient encounters with children. IV.A.6.e).(2) This experience should include a minimum of 75 emergency department patient encounters with children. IV.A.6.f) Residents must have at least 200 hours or two months or 250  patient encounters dedicated to the care of children and adolescents in an ambulatory setting. (Core) IV.A.6.f).(1) This care must include well-child care, acute care and  chronic care.  IV.A.6.g) Residents must have at least 40 newborn patient encounters, including well and ill newborns.