Abstract
Background
Paediatric training programs are committed to graduating paediatricians able to function independently in professional practice. The focus of this study was to gain understanding of a training program’s strengths and deficiencies, while also exploring new methods to aid in transitioning trainees into practice.
Method
Using the CanMEDS framework, semi-structured focus groups were conducted with recently graduated paediatricians. Data were analyzed using qualitative content analysis.
Results
Three focus groups were completed, including a total of nine participants. Key themes were identified pertaining to CanMEDS roles. Particular strengths were found in medical expert for managing acute illnesses, communicator for engaging in difficult conversations, and health advocate in responding to diverse patient populations. Relative deficits were recognized in collaborator for connecting patients with community services, leader related to practice development and management, and scholar for cultivating critical appraisal. Opportunities for training program growth included ensuring community exposures were timely and varied, engaging additional community preceptors in training and giving appropriate expectations and mentoring to trainees to develop as scholars.
Conclusions
Educators need to be mindful of the exposures that trainees receive in residency. New graduates may also ultimately benefit from mentorship in the community or ongoing contact with their past training program.
Keywords: Medical education, Paediatrics, Transition into practice
BACKGROUND
Medical residency training programs are committed to graduating physicians able to effectively meet the needs of the people they serve. Training involves not only acquisition of medical knowledge, but also competences in communication, collaboration, leadership, advocacy, scholarship and professionalism. This has been reflected in the CanMEDS medical education framework, where medical expert is the integrating role of all the others (1). CanMEDS is the basis for training in all specialties and subspecialties accredited by the Royal College of Physicians and Surgeons of Canada (1).
The approach to training residents is changing: trainees will be expected to perform activities with increasing autonomy reflected by the achievement of milestones (2). Existing research suggests that gaps exist in the curricula of paediatric residency programs, thus identifying deficiencies may help future curriculum development (3,4). The final stage of training, transition to practice, represents a unique educational challenge (4). Trainees require opportunities for autonomy yet also guidance for solidifying, finessing, and mastering core roles. There is also the reality that most training is hospital-based, which differs considerably from community-based practice. Educators may be unaware of what gaps exist in their programs because the experiences of those new to practice are not fed back (3).
The aim of this study was to gain understanding of the curriculum of a training program with regards to transitioning residents to general paediatrics practice.
METHODS
Qualitative methods, focus group and content analysis, guided by the CanMEDS framework were utilized. The study was approved by the University of Alberta Research Ethics Board.
Participants
Recent graduates from the University of Alberta Pediatrics Program were invited to participate via email. This program accepts nine Canadian Medical Graduates, and one to two International Medical Graduates each year. Inclusion criteria were graduates who were practicing as general paediatricians for a period of less than 5 years. Based on available records, a total of 23 paediatricians met these criteria. A time period of 5 years was chosen to ensure that the experiences of those recruited were still freshly present in participants’ recollections.
Data collection
Data was collected through focus groups (5,6). This method has the advantage of engaging and prompting discussions between individuals to formulate fresh perspectives, question taken-for-granted attitudes and clarify existing opinions (7,8). Limitations of focus groups relate to individual disclosure, group dynamics and organizational issues (8).
In total, nine recently graduated paediatricians participated in one of three focus group sessions. Two to four participants were included in each, providing an appropriate number for group discussion (6). The CanMEDS framework was used to articulate focus group guiding questions (1). Focus groups were held in May and June 2016, and each lasted approximately 1 to 2 hours. Discussions were audio recorded and transcribed verbatim with identifying features removed.
Data analysis
Data were analyzed using qualitative content analysis (9). This approach provides a summary of the themes raised in the focus group discussions based on an interpretive reading of the contextual meanings of the transcribed text (10).
Transcripts were independently read and coded by the authors. Discussion and comparison of coding informed the final coding and writing of the manuscript. No weight was given to the frequency of particular identified themes given the method of recruitment was in part based on convenience and themes were generated from discussion. Anonymized quotes from the focus group transcriptions are included as evidence for the validity of themes, and to help convey contextual meanings to the reader.
RESULTS
Demographics of participants are presented in Table 1. Themes are grouped under the CanMEDS roles.
Table 1.
Participants’ demographic information
| n=9 | |||
|---|---|---|---|
| Gender | Female | 9 | (100%) |
| Male | 0 | (0%) | |
| Age | 25–29 | 0 | (0%) |
| 30–34 | 5 | (56%) | |
| 35–39 | 3 | (33%) | |
| 40–44 | 1 | (11%) | |
| Years of general paediatrics residency completed | 4 | 8 | (89%) |
| 3 | 1 | (11%) | |
| Years in practice | 1 | 1 | |
| 2 | 1 | ||
| 3 | 4 | ||
| 4 | 3 | ||
| 5 | 0 | ||
| Hospital privileges | Yes | 7 | |
| No | 2 | ||
| Group practice with other paediatricians | Yes | 8 | |
| No | 1 | ||
| Locuming after complete training | Yes | 6 | |
| No | 3 | ||
Medical expert
Trained in recognizing and managing pathology
Graduate paediatricians expressed having received solid training in the requisite medical knowledge and clinical skills for the assessment and management of acute medical issues.
“We get a lot of exposure and responsibility…it was so entrenched after four years of paediatrics of how to deal with… acute situations that I felt really comfortable… going there and being the only paediatrician.”
Clinical teaching unit (CTU), paediatric intensive care and emergency medicine rotations were articulated as fundamental to training. Such training was crucial to not only recognize and initiate management of acute illness, but also exclude worrisome diagnoses.
Dealing with the everyday
Although often having the requisite knowledge, graduate paediatricians variably expressed comfort in dealing with the ‘bread and butter’ medical issues of paediatric practice such as sleep problems, constipation and behaviour issues.
“I mean those things we were taught, those are big things…but we did not really practice [dealing with them in our training].”
As such, it was the common everyday questions, ‘what parents expect you to know’, that graduate paediatricians described being ill-prepared for. Whether questions related to ‘breastfeeding or how long you sterilize bottles’, some graduate paediatricians discussed relying simply on commonsense or actual personal experiences to counsel patient-families.
“I learned more as a parent than I did as a resident for those issues.”
A different practice to residency
Graduate paediatricians described their practices as fundamentally different from the usual inpatient, clinical practice of residency. Following, exposure to community paediatrics was discussed as a potential deficiency in training.
“I think the other thing is just more exposure to community paediatrics and community paediatrics at different stages in your training.”
Timely community exposure commensurate with trainees’ knowledge, experience, and career planning was seen as crucial. Participants described that community preceptors need guidance and support to ensure that residents’ learning needs are met.
Communicator
Practicing communication
Overall participants described being prepared to deal with new communication experiences, and carry out conversations that previously may have been had by their attending staff. Still, having such conversations was not without challenges for some.
“I think we do a lot of the breaking bad news…but just…walking a family through [losing a child] …seeing them back in clinic and kind of those counseling experiences…that was a big learning curve for me…”
Developing new relationships
As a graduate paediatrician, relationships are different with patients and their families. Such changes in relationships were described as an inevitable adjustment on entering into independent practice.
Collaborator
Connecting with colleagues
Graduate paediatricians reported that residency training cultivated collaboration with subspecialists and other colleagues within the hospital environment. Difficulties arouse, however, in knowing how to connect patient-families with services in the community such that collaborating as an experienced partner with patient-families could be challenging.
Relying on existing collaborations
Collaboration with colleagues was frequently discussed as a significant source of support for graduate paediatricians new to practice.
“Rarely are you even in clinic working by yourself, like some days you might be, but otherwise you can always pull someone else in to ask them a question.”
Recognizing the benefits of collaboration, clinic rotations towards the end of residency were discussed as a strategy to forge future relationships to ease transition into practice in addition to consolidating knowledge.
Leader
Professional practice and personal life
Graduate paediatricians discussed how a significant number of their mentors in training were subspecialists, had hospital-based practices, or alternative payment/funding plans. At the time of graduation, many participants discussed being unaware of possible practice variations (particularly fee-for-service) by virtue of the mentors they identified with and the clinic rotations they had completed in residency.
“The experience you are going to get at some clinics is drastically different than what you are going to get at other clinics.”
Trainees may lack understanding of the advantages and disadvantages of all manner of practice variations (e.g., solo versus group practice, fee-for-service versus alternative funding plans, etc.). Thus, a great deal of learning needs to occur while being new to practice to achieve balance between work and personal life.
Missing the business side of medicine
Issues such as financial planning, insurance, incorporation, practice overhead, negotiating contracts and billing/remuneration were seen as relatively neglected topics in residency. Timely seminar sessions introducing such topics were described as invaluable, particularly when such discussions were not incorporated into community rotations.
“Informal evenings in fourth year with the staff that took the time to kind of go through like the medical legal and business side of things and the nuances of paperwork…I found that so valuable, and I want to make sure that that is an experience that residents get.”
Health advocate
Strong training in health advocacy
Paediatricians reported having strong training in health advocacy, recognizing that their new community practice often served a population that was different from residency: ‘the working poor’, ‘immigrant populations’ and particular ‘cultural groups’. In other words, residents felt prepared to learn and adapt to diverse patient populations.
New nuances of advocacy
Regardless of the community of practice, there appeared to be distinctions to health advocacy that were missed in residency training.
“I found a lot of kind of grey area that I thought I had been taught very well…”
Navigating issues related to advocacy coupled with increased responsibility of practicing as an attending physician were described as new responsibilities.
Scholar
Relying on resources for scholarship
Graduate paediatricians described the learning of residency reflecting an effort to obtain needed knowledge. Dimensions of evaluating evidence and contributing to scholarship were relative deficits for some participants.
“In General Paediatrics training I felt very happy if I read UpToDate ® or if I read Pediatrics in Review ® but that is not scholarly, that is really textbook type reading. That is really background versus foreground and questioning…”
Graduate paediatricians reflected that it is possible for a training program to educate their trainees on the needed knowledge for practice yet miss cultivating critical thinking and appraisal skills for future scholarship activities.
Missed expectations
Discussions stressed that training in scholarship needs expectations placed on trainees for completing literature searches, evaluating the available evidence and posing future research questions so trainees develop as scholars to incorporate lifelong learning into their day-to-day practice. Developing as a scholar requires coaching and mentorship. If mentors are not demonstrating engagement with the literature in their day-to-day practice, scholarship may lose its integration with clinical training.
Professional
Ownership and commitments to patients and their families
Longitudinal exposures, such as continuity clinics, were reported as possible methods for cultivating responsibility in training. Graduate paediatricians, however, discussed the challenges of incorporating these experiences into their training.
“We do so much CTU, I felt it was frowned upon to do continuity clinic when I was on CTU so if I am doing four months of CTU, how do I get away to my continuity clinic?”
Given competing education opportunities, continuity clinics were often fraught with scheduling issues. When these clinics were of a discontinuous or sporadic nature, their utility for the purpose of continuity and immersive learning were put in question relative to actual rotations in community practice.
Developing professional identity
Participants discussed the professional and educational value of attending a greater variety of community practices in residency, as well as inviting paediatricians from different types of practices to share their experiences.
“I think if you are able to make the contacts, and give some information about the types of clinics that these people run, the types of practices these people have, I don’t think you necessarily have to create more time.”
Exposures and disclosures need to be timed appropriately during paediatric resident training to afford opportunities for career planning and professional development. Recognizing the intent is to gain understanding on a variety of community practices, the goal is different from what is achieved from a continuity clinic in a single practice rotation. In comparison, interim or temporary work for an established physician following graduation was seen as valuable to broaden exposure, experience possibilities for practice and develop professionally by a number of graduate paediatricians.
DISCUSSION
The findings of our study are in keeping with the existing literature that gaps exist in the training curricula of Canadian paediatric residency programs (3,4). Rather than focus on particular content deficiencies, we explored holistically how prepared graduate paediatricians felt they were at graduation with respect to CanMEDS competencies.
Particular strengths were identified within medical expert for recognizing and managing acute illnesses, communicator for engaging in difficult conversations and health advocate in responding to the needs of diverse patient populations. Greater deficits were recognized in collaborator for connecting with services in the community, leader related to practice development and management and scholar for cultivating critical appraisal and evidence synthesis. This could be due to gaps in the education provided, or alternately because these competencies can only be fully gained when learners are in actual practice. While it is unclear whether these strengths and challenges are currently shared by other training programs, such knowledge, and the process of generating such knowledge (qualitative methods), may be useful for other programs as they critically review how they are preparing their graduates for independent practice. As we move forward in competency-based education, we need to determine what should be expected of trainees by the completion of training, and whether certain competencies are better supported during graduate physicians’ first years of practice. Time is clearly a valuable commodity in residency training, particularly with the possibility of changes in duty hours, as well as demands on residents in terms of scholarly activities (11,12).
Ensuring paediatrics exposures are timely, varied and ultimately meaningful may be helpful to orient trainees to needed learning for independent practice in community settings (13). Similarly, engaging an appropriate breadth of mentors in residency is likely beneficial given the formative effect mentorship may have on professional growth (14). Training could also be strengthened by including a specific transition to practice curriculum, covering topics that may otherwise be missed. Lecture curriculums, either delivered longitudinally over a training program or as single-day seminars, have shown success in covering topics such as personal finances, leadership skills, job hunting and contract negotiation (15). Such curriculum and support may be appropriate beyond the residency program to support clinicians new to practice. In one study, formal mentor pairing after residency graduation resulted in less adverse patient events, confidence in new endeavours and a sounding board for clinical problems (16).
Future directions will include development of a transition to practice curriculum. Our longitudinal clinic experience is being reviewed to provide more emphasis on competencies related to practice management. In addition, we will be implementing a lecture series to provide a graded exposure to topics such as connecting patients with community services, continuing professional education and financial planning. Last, we will be looking at how we can provide better mentorship both within the program and after graduation to ensure trainees and new staff are appropriately supported.
Although we do feel that the various themes raised in this study do warrant consideration by other training programs, it is important to acknowledge limitations. Our recruitment included a small selection of paediatricians graduating from a single training program who volunteered to participate. More so, we only included trainees who ultimately choose to practice general paediatrics locally.
CONCLUSION
Educators need to be aware of the kind of exposures that trainees receive in residency. There appear to be some consistent deficiencies in the curriculum of trainees that can be addressed by modification. New graduates may also ultimately benefit from mentorship in the community from senior physicians or ongoing contact with their past training program as they enter into professional practice.
Conflict of Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding Source: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Women & Children’s Health Research Institute.
Financial Disclosure: The authors declared no financial relationships that could be broadly relevant to the research, authorship, and/or publication of this article.
Clinical Trial Registration: Not applicable
Ethics Board: Approved by the University of Alberta Research Ethics Board.
References
- 1. Frank JR, Snell L, Sherbino J. ed. The Draft CanMEDS 2015 Physician Competency Framework–Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2015 March. [Google Scholar]
- 2. Frank JR, Snell LS, Cate OT et al. Competency-based medical education: Theory to practice. Med Teach 2010;32(8):638–45. [DOI] [PubMed] [Google Scholar]
- 3. Kumar G, Ni A, Lawrence SE, Doja A. Incorporating CanMEDS and subspecialty training into paediatric residency programs: Why are we still deficient?Paediatr Child Health 2012;17(1):e7–e11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Lieberman L, Hilliard RI. How well do paediatric residency programmes prepare residents for clinical practice and their future careers?Med Educ 2006;40(6):539–46. [DOI] [PubMed] [Google Scholar]
- 5. Bryers P, Wilcox JR.. Focus Groups: An Alternative Method of Gathering Qualitative Data in Communication Research. New Orleans: Speech Communication Association; 1988. Report No.: C5-506-291. [Google Scholar]
- 6. Greenbaum TL. The Practical Handbook and Guide to Focus Group Research. Lexington: Lexington Books; 1988. [Google Scholar]
- 7. Kitzinger J. Qualitative research. Introducing focus groups. BMJ. 1995; Jul 29; 311(7000):299–302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Krueger RA. Focus Groups: A Practical Guide for Applied Research. London: Sage. [Google Scholar]
- 9. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277–88. [DOI] [PubMed] [Google Scholar]
- 10. Tesch R. Qualitative Research: Analysis Types and Software Tools. Bristol: Falmer; 1990. [Google Scholar]
- 11. Pattani R, Wu PE, Dhalla IA. Resident duty hours in Canada: Past, present and future. CMAJ 2014;186(10):761–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Sabri N, Sun NZ, Cummings BA, Jayaraman D. The perceived effect of duty hour restrictions on learning opportunities in the intensive care unit. J Grad Med Educ 2015;7(1):48–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Goldshore MA, Solomon BS, Downs SM, Pan R, Minkovitz CS. Residency exposures and anticipated future involvement in community settings. Acad Pediatr 2014;14(4):341–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Umoren RA, Frintner MP. Do mentors matter in graduating pediatrics residents’ career choices?Acad Pediatr 2014;14(4):348–52. [DOI] [PubMed] [Google Scholar]
- 15. Babitch LA. Teaching practice management skills to pediatric residents. Clin Pediatr (Phila) 2006;45(9):846–9. [DOI] [PubMed] [Google Scholar]
- 16. English D, Edwards R, Genday P, Maue C, Zydel C. Smoothing the transition from resident to attending physician using mentors. Physician Exec 2013;39(6):44–8. [PubMed] [Google Scholar]