1. Residency Review and Redesign in Pediatrics (R3P) Project
Durham, NC
August 1-3, 2007

2. This provides perspective on the R3P Project
This provides perspective on the R3P Project. This brief document was the first to provide written guidelines for pediatric residency programs.

3. It was followed in 1978 by this comprehensive 120 page Report
It was followed in 1978 by this comprehensive 120 page Report. The Task Force consisted of representatives of Pediatric Department Chairs, the American Academy of Pediatrics, the American Board of Pediatrics, the three Pediatric Academic Societies, the American Medical Association Residency Review Committee and several subspecialty societies. This so-called FOPE I Report was the precedent for the Future of Pediatric Education (FOPE) II Project.
1978

4. Future of Pediatric Education (FOPE I) - 1978
Minimum duration of residency should be 36 months
Need for increased educational experience in:
Biosocial and developmental pediatrics
Adolescent medicine
Clinical pharmacology and toxicology
Community pediatrics
Handicapping conditions and chronic illness
Medical ethics
Musculoskeletal, skin, and dental disorders
Nutrition
Elective experience in areas of special interest
Important elements of these suggestions were not incorporated into pediatric residency training requirements until the 1990’s.

5. Will History Repeat Itself?
“The Task Force’s ten sponsoring organizations and the readers of this report must assume responsibility for continuing the process of reevaluation, incorporating into educational programs as many of the Task Force’s recommendations as continue to seem appropriate, and devising new recommendations to meet emerging needs.”
Forward, The Future of Pediatric Education, 1978
This is a quote from the 1978 report. Despite good intentions, many recommendations were not instituted for some 15 years. The RRC for Pediatrics has done its best in that regard, but the weight of everyday RRC regulatory responsibilities is large. Thus change has been slow and incremental. Consideration of substantial, strategic changes awaits the results of the R3P project, 30 years later. Pediatrics needs to create mechanisms for ongoing evaluation and adaptive change in graduate medical education.

6. This major effort was vast in scope and set the stage for the R3P Project. It represents a comprehensive review of societal issues affecting children, adolescents and parents, and Pediatrics then (2000) and in the future. It was led by Jimmy Simon and Russ Chesney.

7. Future of Pediatric Education II (FOPE II) - 2000
Enhancement of the science of pediatric medical education
Flexible 3-year residency to train pediatricians for varied professional roles
Development, ongoing revision and evaluation of core competencies and core curriculum
Adjustments to residency training as the product of ongoing attention by all pediatric organizations
Importance of career counseling and mentorship
Individualized professional education plan for 3rd year residents incorporating anticipated needs for future practice
The FOPE II recommendations that relate to education per se differ little from likely recommendations by the R3P Project. The R3P Project is obligated to work in partnership with others to find ways of putting recommendations into practice, monitoring implementation and providing for ongoing evaluation and modification.

8. Where We Began Review current training in light of:
thematic aspects of the future of health care for children and adolescents
knowledge, skills and attitudes needed for that future
current understanding of medical education
Make recommendations for changes in pediatric graduate medical education
Current pediatric residency education is much the same from one program to the other. This reflects custom more than regulatory requirements. Viewed in the context of education in general, this is not surprising. Until relatively recently, institutions of higher education, including medical schools, have been quite conservative. The irony of such institutions promoting innovation while being themselves reluctant to change has been noted. The R3P Project began in the same mode. Implicit in the initial proposal was the concept of a single “better” model.

9. Emergent Opportunities
To use flexibility within the current residency (9-16 of 33 months) to explore innovations that serve patients through better resident education
To come to terms with the implications of the “continuum of medical education”:
Residency is not an island, entire of itself.
Residency is not the time or place for all learning.
To facilitate ongoing, post-R3P innovation, evaluation and improvement
Beyond a “better present”
A complicated administrative undertaking
As we began to talk and read, we became aware of opportunities. We noted that the content of up to 16 of the current 33 months of training is not precisely specified by the RRC. This could be used in innovative ways. Why has that not occurred? We agreed that residency needs to be thought of as part of a continuum of education that serves a continuum of learning. That might relieve residency of some of its responsibilities, some unlikely to be satisfactorily fulfilled under any circumstances: the resident/learner is not necessarily ready nor is the residency learning environment necessarily appropriate for achievement of competency in all areas. Education as a continuum raises the possibility of new approaches to residency per se. We began to think about residency after R3P. Suggestion of a a new, single model implies a future major initiative to suggest another new, single model. It seems better to establish a process by which residency training would continually adapt to an unpredictable future. The concept of continual adaptive change in graduate medical education has been advanced by ACGME. But the ACGME requirement could be satisfied by gradual modification of the current model. Internal Medicine and Family Medicine have taken the concept to another level by allowing programs to experiment with different models, a process of dynamic decentralized innovation. A decision to follow their example would represent a departure from our initial thinking.

10. Where We Are Now
Discussion of a QI approach to innovation in Pediatric GME
Prescribes specific, measurable outcomes, not process
“Offers a path forward”
Takes advantage of situation-specific opportunities, strengths, imagination, energy
Early positive responses to the concept from AAP Resident Section, APPD, AMSPDC, ABP committees, RRC for Pediatrics, PAS
We have begun to discuss a “QI” approach to innovation. Some important features are listed. We have had early positive responses. This may not predict the breadth of responses to a detailed proposal. Some programs will not be able to try truly different approaches because of current shortcomings. Some of those eligible will decline to participate for various reasons. Few will take on a QI education project without encouragement and guidance.

11. The “Competencies” A Conceptual Sea Change
Outcomes as Competencies
Medical knowledge
Patient care
Professionalism
Interpersonal and communication skills
Systems-based practice
Practice-based learning and improvement
Configures the conversation, sets the agenda: a profound culture shift
Sets the stage for an outcomes-driven QI approach to Pediatric GME
Performance, and therefore education, outcomes for physicians are summarized by the six Competencies adopted by the Accreditation Council for Graduate Medical Education and thus the RRC for Pediatrics for training programs in Multi-year implementation began in The competencies were also adopted by the American Board of Medical Specialties, of which the American Board of Pediatrics is a member, for professional certification. Reconfiguring graduate medical education around goals has changed the conversation and the agenda for reform. This sets the stage for viewing Pediatric Residency Education as an ambitious quality improvement project.

12. Synchrony with ACGME Outcome Project
The approach is consistent with the ACGME Outcomes Project as well as with the Internal Medicine RRC’s Educational Innovation Project (details on the ACGME web site). The Family Practice RRC has also used at RFA approach to encourage innovation (details on the American Board of Family Medicine web site).

13. So What Can R3P Add? Clarification of purpose Ambition Facilitation
Measure education outcomes
Better education as the first step to more informed, better care
Measure health outcomes where possible
Ambition
Strive for the optimum
Minimize narrow interpretation of “evidence that programs are making data-driven improvements”
Facilitation
Guidance
Incentives
One might reasonably ask, “If residencies are already doing this, what does R3P have to contribute?” The requirement that one must show evidence of data-driven improvements can be met in a minimum way or can be taken as a challenge. It can be undertaken as a few short-term projects or as a long-term, ambitious strategy. It has been said that perhaps 20% of all GME programs in the country have adopted the rationale and concepts of the ACGME Outcome Project, with perhaps 10% vigorously objecting and the rest just wanting to know what they need to do to “pass” and be accredited. R3P can steer Pediatrics toward the first group by making clear the benefit for children, adolescents and families. It can encourage measurement of education outcomes, on the reasonable assumption that better educated physicians provide better care, and can encourage measurement of health outcomes where possible. R3P can foster the excitement and intense engagement that are vital to accomplishment. In this colloquium we will explore the rationale for innovation, specifically the rationale for areas of concentrated learning according to career objectives, and possible models for innovation.

14. Goals for Colloquium III
Develop and prioritize goals for innovation in residency [“goals for an outcomes-based innovation process”]
Create examples of innovative models to achieve the innovation goals
Consider differences in pediatric practice
Determine whether differences in pediatric practice justify some variation in pediatric training
Determine the direction for R3P and the future for R3P initiatives
Thus our goals for this Colloquium are as above.