Детский Национальнa Медицинский Центр Университет Джорджа Вашингтона Вашингтон

Детский Национальнa Медицинский Центр, Университет Джорджа Вашингтона, Вашингтон, США Подготовка врача-педиатра: Система медицинского образования в США Натэлла Рахманина Доктор Наук Адъюнкт-Профессор Директор Программы Специммунологии April 15, 2014

Pediatrics in the US • Born and trained in medicine in Germany • Lived and practiced in New York City • Children’s Hospital of Philadelphia – 1855 • Boston Children’s Hospital – 1869 • Children’s National Health System – 1870 • Today - ~250 pediatric hospitals in the US Abraham Jacobi 1830– 1919

Pediatric Medicine in the US • Pediatrics in the US represents the branch of medicine that deals with care of infants from birth, through childhood and adolescence until 21 years of age • For certain chronic medical conditions the upper limit for age can be extended to 24 years of age and older • Majority of the pediatric subspecialties require training in pediatrics as a first step followed by more specialized training in a fellowship program

Pediatric Subspecialties in the US • Adolescent Medicine • Pediatric Gastroenterology • Pediatric Cardiology • Pediatric Hematology. Oncology • Child Abuse • Pediatric Infectious Diseases • Pediatric Critical Care Medicine • Neonatal-Perinatal Medicine • Developmental. Behavioral Pediatrics • Pediatric Nephrology • Pediatric Emergency Medicine • Pediatric Pulmonology • Pediatric Endocrinology • Pediatric Rheumatology

Medical Training Grade school & High school – 12 years (6 -18 years of age) College – 4 years (may be less or more) Medical school – 4 years Qualifying exams for entry into Medical School Vigorous selection process involving transcripts from college, exams, letters of the recommendation and curriculum vitae • Previous experience in research, volunteer work matter! • In person interview is required • • •

Residency in Pediatric Medicine • 3 years in training at accredited Pediatric Residency Programs following completion of medical school • Vigorous selection process at each program • Application involves transcripts of the medical school, exams, letters of the recommendation and curriculum vitae • Previous experience in research and academic output matter! • Additional degree matters • In person interview is required • Computerized matching process at the end determines the final selection

Accreditation of the Pediatric Residency Program • Site visit every 10 years • Yearly surveys of the residents, fellows tailored to evaluate their perception of their educational experience, clinical experience • Yearly survey of the faculty tailored to evaluate the protected time for teaching, continued medical education • Yearly data on the program scholarly productivity (faculty and fellows) including publications, presentations, national recognition • Data on the ABP and subspecialty Boards certification success of the graduates

February 8, 2018

Children’s National Health System Residency Training Program • 3 year program with 120 residents • 2600 applicants representing 63% of all medical students applying for training in pediatrics • 500 invited for an interview, 40 selected • Six tracks available (primary care, community health, categorical, child neurology, neurodevelopmental disabilities, medical genetics track) • Yearly in service exams to access the progress in training and preparation for the Certifying American Board of Pediatric Exam

Children’s National Health System Residency Training Program • Fixed number of obligatory rotations with several months of electives and opportunity for research during third year • Maximum 80 hours per week, 16 hours shifts • The longest time of uninterrupted service up to 28 hours, no more than 24 hours direct patient care • Daily rounds with an attending and medical team • Separate teaching rounds (3 -4 times weekly) and simulation training (1 -2 times per week) • Weekly interactive professorial rounds and weekly hospital grand rounds

REACH Program • Research , Education, Advocacy and Child Health Care • Half day per week second and third year of training • REACH results 2013: ü 11 peer-reviewed manuscripts published ü 6 awards at the institutional and national levels ü 12 grants awarded ü 33 abstracts presented at the regional, national and international meetings

February 8, 2018

The Pediatric Milestone Project • Joint Initiative of the Accreditation Council for Graduate Medical Education and American Board of Pediatrics • Feedback from the Association of Pediatric Program Directors • Follow up through the Longitudinal Educational Assessment Research Network

Performance oriented and Practice based Competencies Evaluated at 5 levels • • Patient care Medical knowledge Practice-based learning and improvement Interpersonal and communication skills Professionalism System-based practice Personal and professional development

Patient Care Competency • Gathering detailed anamnesis • Organizing and prioritizing responsibilities for safe, effective and efficient patient care • Assuring seamless transition of care • Interviewing patients and families for the medical condition • Complete and accurate physical examination • Making therapeutic and diagnostic decisions that result in optimal clinical judgment • Develop and carry out management plan

Patient Care Competency • Prescribe and perform all medical procedures • Counsel patients and families • Provide effective health maintenance and anticipatory guidance • Use information technology to optimize patient care • Provide appropriate role modeling • Provide appropriate supervision

Entrustable Professional Activities (EPAs) Early Development Intermediate Development Advanced Development

Example of Entrustable Activities • Observer - observation only • Advance beginner – partial involvement in assessment and care • Direct supervision - supervised assessment and care • Indirect supervision – independent assessment, discussion of care plan, independent care • Proficient – independent assessment and care • Mastery – supervision of others

Innovative Approaches to Training Active instead of passive learning Concept of knowledge “pearls” Regular feedback to the trainee and to the trainer Evaluations of trainees oriented at “what would you be able to do” • Evaluations of trainer oriented at “how can I help you to learn and master” • Algorithms for assessment and care • Cross-training with nursing and physician assistants • •

Acknowledgments • Mary Ottolini , MD, MPH, Vice Chair for Medical Education, Professor of Pediatrics, George Washington University, Children’s National Health System • Dewesh Agrawal, MD, Director, Pediatric Residency Program, Associate Professor of Pediatrics and Emergency Medicine, George Washington University, Children's National Health System

“Pediatrics does not deal with miniature men and women, with reduced doses and the same class of diseases in smaller bodies, but…. it has its own independent range and horizon…” Dr. Abraham Jacobi, 1889