The training paths and practice patterns of Canadian paediatric residency graduates, 2004–2010

Abstract

BACKGROUND:

The Paediatric Chairs of Canada have been proactive in workforce planning, anticipating paediatric job opportunities in academic centres. To complement this, it is important to characterize the practice profiles of paediatricians exiting training, including those working outside of tertiary care centres.

OBJECTIVE:

To describe the training paths and the practice patterns of Canadian paediatric residency graduates.

METHODS:

A survey was completed in 2010 to 2011 by Canadian program directors regarding residents completing core paediatrics training between 2004 and 2010. Data collection included training path after completing core paediatrics training and practice type after graduation.

RESULTS:

Of 699 residents completing their core training in paediatrics, training path data were available for 685 (98%). Overall, 430 (63%) residents completed subspecialty training while 255 (37%) completed general paediatrics training only. There was a significant increase in subspecialty training, from 59% in earlier graduates (2004 to 2007) to 67% in later graduates (2008 to 2010) (P=0.037). Practice pattern data after completion of training were available for 245 general paediatricians and 205 subspecialists. Sixty-nine percent of general paediatricians were community based while 85% of subspecialists were hospital based in tertiary or quaternary centres. Of all residents currently in practice, only 36 (8%) were working in rural, remote or underserviced areas.

CONCLUSIONS:

Almost two-thirds of recent Canadian paediatric graduates pursued subspecialty training. There was a significant increase in the frequency of subspecialty training among later-year graduates. Few graduates are practicing in rural or underserviced areas. Further studies are needed to determine whether these trends continue and their impact on the future paediatric workforce in Canada.

There is a concern that fewer paediatric graduates in Canada are pursuing community paediatric practice, and most work in urban centres, which affects children’s access to health care (1). To date, there have been little data profiling the actual training paths and practice patterns of Canadian paediatric residents. Two studies exploring how well Canadian paediatric residency programs prepared residents for clinical practice showed an approximately equal split between general paediatrics and subspecialty (SS) paediatrics among graduates (2,3). However, the main focus of these studies was on assessing the adequacy of training and not on profiling the career paths of residents. The aim of the present study was to describe the training paths and practice patterns of graduates of Canadian paediatric residency programs.

METHODS

A survey was sent to all program directors of accredited paediatrics residency programs in Canada for completion by Canadian and international medical graduates who completed three years of core paediatrics training during the study period (2004 to 2010). Visa trainees sponsored by foreign countries were excluded. One program (Northern Ontario School of Medicine, Sudbury, Ontario) was excluded because it was a new program at the time the survey was distributed.

Three training paths were identified: four years of general paediatric training; four years of general paediatric training followed by SS training; or three years of core training followed by SS training. Practice patterns were classified according to clinical focus (general or SS paediatrics) and practice type (community or hospital based, with the latter implying work in a tertiary/quaternary centre). Community-based practices could either be in a rural/remote/underserviced area or in an urban centre. Rural practices were not specifically defined. For urban practices, general paediatrician practices were identified as ≥50% consulting paediatrics or ≥50% primary care and SS practices. Please refer to Appendix 1 for details regarding training paths and practice pattern categories. Program directors (or their designees) were asked to complete the surveys about their own graduates. Regarding practice type, they were asked to choose only one category (the primary practice pattern of the graduate). Ethics approval for the present study was obtained from the Research Ethics Board at the Children’s Hospital of Eastern Ontario, Ottawa, Ontario.

The survey instrument was piloted in one program and then mailed to all paediatric programs in the country in 2010. The survey was slightly modified and, in 2011, resent to the program directors via e-mail and distributed at the annual program directors meeting to gather updated data.

Training and practice patterns are presented as frequencies. Data analysis was performed using SPSS version 22 (IBM Corporation, USA). The χ² test was used to compare frequencies according to years of training and size of training program; differences with P<0.05 were considered to be statistically significant.

RESULTS

Training paths of Canadian paediatric residents

A total of 699 residents completed their core training in paediatrics in Canada between 2004 and 2010. The number completing core training rose annually from 83 in 2004 to 122 in 2010. Training path data were available for 685 (98%) residents. Overall, 430 (63%) residents completed SS training while 255 (37%) completed general paediatric training alone. Among residents who completed SS training, 265 (62%) entered SS training after three core years of general paediatrics, while 159 (37%) completed four-years of general paediatrics before their SS training. The exact SS entry point was unknown for six (1%) residents. Eight residents completed SS training in the United States.

Training years were categorized as early (2004 to 2007 [n=354]) or late (2008 to 2010 [n=331]). Fifty nine percent in the early group completed SS training compared with 67% in the late group (P=0.037). There was no difference between the early and late groups with respect to entering SS training after three versus four core years of training (P=0.229).

The 16 paediatric residency training programs were arbitrarily classified as large (≥10 residents per year), medium (five to nine residents per year) and small (≤4 residents per year) programs. The percentage of residents completing SS training was 67% in large and medium-size programs versus 54% in small-size programs (P=0.004).

During the study period, two Ontario paediatric residency programs offered northern Ontario training streams (McMaster University [Hamilton, Ontario] and University of Ottawa [Ottawa, Ontario]). Seventeen residents completed their core training in these northern programs, of which 53% completed general paediatric and 47% completed SS training.

Practice patterns of Canadian paediatric residents

The practice type was available for 465 of the 699 (67%) Canadian paediatric graduates during the period 2004 to 2010. The practice profile of these graduates was: 245 (53%) working as general paediatricians; 205 (44%) as subspecialists; and 15 (3%) with other practice types (eg, international health, administration, etc). Two-hundred residents were still in training at the time of the survey and the current practice type for 34 other graduates was unknown. Of the 465 graduates in practice, only 36 (8%) were working in rural, remote or underserviced areas.

Of the 245 graduates working as general paediatricians, 167 (69%) were in community-based practice and 78 (31%) were hospital based. Of the community-based paediatricians, 112 (67%) were working as consulting paediatricians in urban centres, 34 (20%) as consulting paediatricians in rural, remote or underserviced centres, and 21 (13%) were working in urban centres with a largely primary care practice. When comparing early (2004 to 2006 [n=99]) and late (2007 to 2009 [n=116]) cohorts of general paediatricians, there was no significant difference in the proportion working in community practice (61% versus 70%; P=0.156). Data for the 2010 graduates (n=30) was not included in this comparison because many graduates were still in training.

Of the 205 graduates working as subspecialists, 174 (85%) worked in hospital-based tertiary/quaternary centres, 29 (14%) as community-based subspecialists in urban centres and two (1%) in rural/remote areas.

DISCUSSION

To our knowledge, the present study was the first to profile the training paths and practice patterns of Canadian paediatric residency program graduates. Over the years of the present study, there was a significant increase in the percentage of residents choosing SS training (from 58% in 2004 to 2007, to 65% in 2008 to 2010), which is multifactorial. From 2000 to 2010, several SS programs were newly accredited by the Royal College of Physicians and Surgeons of Canada, and many of the academic paediatric departments in Canada were expanding. In 2003/2004, there were 960 paediatric subspecialists working in academic health science centres in Canada and this increased by approximately 20% to 1140 in 2005/2006 (4). Increased job availability may have influenced paediatric graduates choice to pursue SS training. Lifestyle factors may have also influenced paediatric residents’ career path decision. It has been shown that medical students choosing paediatric careers anticipate lower income as general paediatricians (5), and the attraction for specific paediatric subspecialties may be linked to economic reward (6) in addition to clinical and academic interest.

The current study revealed no significant difference in early and late graduate groups in terms of entry point into SS training (after three or four years of general paediatric training), with approximately two-thirds of paediatric residents selecting the earlier entry point. While reasons for choosing the entry point are unknown, there may be personal considerations or program preference.

Residents in medium to large training programs were more likely to choose SS training. Slightly more than one-half of graduates from small programs entered SS training, compared with approximately two-thirds of medium- and large-program graduates. These findings are consistent with a large study involving American and Canadian paediatric residents taking the American Board of Pediatrics in-training examination in 2007 (7). Differential exposure during training is likely to influence career choices. Paediatric residents in medium to large programs generally devote a higher proportion of their time in large tertiary care hospitals with more exposure to paediatric SS services. In contrast, residents in small programs often experience more exposure to generalists and more community-based rotations, potentially giving them a better understanding of the opportunities and logistics of community-based general paediatric practice.

Among general paediatricians, there was a trend over time toward an increase in community-based versus hospital practice. The trend toward hospital-based jobs in the early years may, again, be due to the growth of the Canadian paediatric academic workforce during the first decade of the 21st century. Many SS trainees were still in training at the conclusion of the present study; therefore, we were unable to analyze trends in SS practice patterns over time.

Our study results have the potential to add valuable information to assist with paediatric workforce planning in Canada. While there is no optimal ratio of general paediatricians versus subspecialists in Canada, there is a shortage of paediatricians in rural and under-serviced areas. Approximately one in five Canadians live in rural areas (8), yet <1 in 10 recently graduated paediatricians established practices in rural or underserviced areas in Canada. Thus, Canadian paediatric programs may not be producing graduates that meet the needs of the paediatric population. Canadian studies by Rourke (9) and Hoegenbirk et al (10) indicate that rural/regional specialty postgraduate training rotations can encourage many specialty residents to establish rural and regional practices. Of note, 70% of graduates from the University of Ottawa – Northeastern stream program, where residents devote approximately 40% of their time in the near north working with consultant paediatricians, were working as general paediatricians in smaller communities. At the same time, the traditional Ottawa program graduated eight (22%) paediatricians who were working in rural/underserviced centres, still considerably higher than the national rate of 8%. More research is needed to evaluate whether the degree of exposure to rural practice and new paediatric residency programs with a stronger rural focus (eg, Northern Ontario School of Medicine) increase the likelihood of graduates working in rural and remote communities.

Existing national data regarding the training and practice patterns of Canadian paediatric residents are limited. The Canadian Post-MD Education Registry database houses details of annual numbers of SS residents in each discipline, but does not detail the practice type (ie, general paediatric versus SS practice) (11). The National Physician Survey 2004 and 2013 showed significant changes in the primary work setting over the nine-year period, with younger pediatricians (35 to 44 years of age) working less in community settings. Details regarding the actual practice patterns of new graduates were not the focus of this survey (National Physician Survey, unpublished data). Finally, the most recent Canadian Paediatric Society physician survey conducted in 2012 was not designed to provide details about the practice settings of general paediatricians and paediatric subspecialists (Canadian Paediatric Society, unpublished data).

As stated by Piedboeuf et al (12), there is neither a national paediatric subspecialist human resource planning, nor evidence available to guide health care authorities toward a needs-based distribution of paediatric subspecialists in Canada. These authors questioned whether residency training programs should be counselling residents to make their career choices based on projected needs or based on residents’ personal passion for a particular area. The distribution of physicians – not simply the absolute supply – is important in health human resource planning (13).

There were several strengths to our study. The present analysis was the first Canadian study to investigate the detailed training paths and practice patterns of Canadian paediatric residents. There was 100% participation of paediatric residency programs, resulting in data for 98% of residents. In particular, we present the first data regarding the specific breakdown of community-based general paediatricians (primary care, consulting and rural practice) and subspecialists (hospital based in tertiary centres versus community based). The primary limitation of the present study was that our data were collected in 2010 to 2011 and, in the past five years, there has been an anecdotal shift back toward general paediatric training from SS training. Second, many of the SS residents were still in training at the completion of the survey and we do not have followup data of their practice patterns. While we anticipate that most residents completing SS training will work as subspecialists, there may be some who cannot find jobs in their fields and work as general paediatricians. Also, our data did not capture ‘combined’ practices (eg, combined general paediatric and subspecialty practices) or other practice types (eg, hospitalists). Finally, sex of the resident was not collected on our data sheets.

CONCLUSION

Almost two-thirds of Canadian paediatric residents who completed their core training in 2004 to 2010 pursued SS training. This represents a change from one decade previously, in which there was an approximate equal number of graduates who were pursuing general paediatric and SS careers. Optimally, the data collection would be extended to track ongoing trends in practice patterns of graduates five, 10 or more years after graduation. Future research can also survey other factors influencing career choice including job availability for paediatricians in Canada.

APPENDIX 1. Data summary sheet for training paths and practice patterns of Canadian paediatric residency graduates

Program name:	2004	2005	2006	2007	2008	2009	2010
1. In June of this year, how many residents completed 3 core years of pediatrics in your program (excluding Visa trainees)
2. Of all the residents in question 1, how many went on to (choose only ONE for each resident):
4th year in general pediatrics followed by no subspecialty training
4th year in general pediatrics followed by subspecialty training
4th year as their first year of subspecialty training
Subspecialty training in the United States
Did not complete subspecialty training (eg, withdrew)
Unknown
Other (please describe)
3. Of all the residents in Q1, what is the PRIMARY focus of their current practice (choose only ONE for each resident)?
General pediatrics, community-based in a rural/remote/underserviced centre (practice affiliated with a community hospital)
General Pediatrics, community-based in an urban centre (>50% consulting pediatrics)
General pediatrics, community-based in an urban centre, (>50% primary care pediatrics)
General pediatrics, hospital-based in a tertiary/quaternary centre
Subspecialty pediatrics, community-based in a rural/remote/underserviced area (practice affiliated with a community hospital)
Subspecialty pediatrics, community-based in an urban centre (associated with a community hospital or <50% of time affiliation with a tertiary/quaternary centre)
Subspecialty pediatrics, hospital based in a tertiary or quaternary centre
International health work (>50% of time)
Still in training
Practicing pediatrics outside of Canada
Not practicing pediatrics
Other (please describe)
Completed training, practice profile unknown