Training Gaps for Pediatric Residents
Planning a Career in Primary Care: A
Qualitative and Quantitative Study
Adam A. Rosenberg, MD
Carol Kamin, MS, EdD
Anita Duhl Glicken, MSW
M. Douglas Jones Jr, MD
Studies of pediatric residency as preparation for general
pediatric practice have reported shortcomings in such topics
as developmental and behavioral pediatrics, mental health,
adolescent medicine, and sports medicine.1–3The importance
of these disciplines has recently been confirmed by an
analysis of the frequency with which these competency areas
are required in general pediatric practice.4These findings are
similar to data reported previously from the United States
and Australia.5,6A different way of looking at the challenges
of primary care is provided by a list of the 50 conditions most
commonly referred for specialty and subspecialty
consultation in the Pediatric Research in Office Settings
Network reported by Forrest et al.7Referral patterns confirm
the importance of training in development and behavior,
mental health, and orthopedic trauma.
We conducted a needs assessment as part of a project to
improve preparation for a career in primary care pediatrics in
our residency program. Following the study of Camp
et al,1we surveyed recent graduates of the University of
Colorado School of Medicine/The Children’s Hospital
Pediatric Residency Program. Second, we conducted focus
groups with pediatricians in private practice. This qualitative
approach enabled ustobetter understandtheir perceptionsof
residency as preparation for community practice.
A survey was sent each year to residents completing the
University of Colorado Denver (UCD) pediatric residency
training program in the years 2003–2006. The survey was
sent 3 years after residency completion. It measured recent
graduates’ perceptions early in their careers of how well
they were prepared for their chosen careers. A single
question addressed each of 12 content areas. Content areas
represented the breadth of pediatric training described in the
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Funding: The authors report no external funding source.
At the time of writing, 3 of the authors were at the Department of Pediatrics,
University of Colorado Denver School of Medicine and The Children’s Hospital
Denver. Adam A. Rosenberg, MD, is Professor of Pediatrics and Program
Director of the Pediatric Residency Program; Anita Duhl Glicken, MSW, is
Professor of Pediatrics, Associate Dean for Physician Assistant Studies, and
Director of the CHA Physician Assistant Program; M. Douglas Jones Jr, MD, is
Professor of Pediatrics and Senior Associate Dean for Clinical Affairs; and Carol
Kamin, MS, EdD, is Associate Professor in the Department of Medical
Education, University of Illinois College of Medicine at Chicago.
Corresponding author: Adam A. Rosenberg, MD, The Children’s Hospital, Box
B158, 13123 East 16th Avenue, Aurora, CO 80045, 720.777.5332,
Received July 1, 2010; revision received January 14, 2011; accepted April 6, 2011.
entails similar training for all residents in a fragmented
curriculum with relatively little attention to the career
plans of individual residents.
Objectives To explore strengths and gaps in training for
residents planning a career in primary care pediatrics and
to present strategies for addressing the gaps.
of Colorado Denver Pediatric Residency Program (2003–2006)
3 years after completion of training. Respondents were asked
to evaluate aspects of their training, using a 5-point Likert
scale and evaluating each item ranging from ‘‘not at all well
prepared’’ to ‘‘extremely well prepared’’ for their future career.
8 pediatric practices in Colorado. Sessions were transcribed
and hand coded by 2 independent coders.
training in pediatrics currently
Results Survey data identified training in behavior and
development (mean score, 3.72), quality improvement and
patient safety strategies (mean, 3.57), and practice
management (mean, 2.46) as the weakest aspects of
training. Focus groups identified deficiencies in training in
mental health, practice management, behavioral medicine,
and orthopedics. Deficiencies noted in curriculum structure
were lack of residents’ long-term continuity of relationships
with patients; the need for additional training in knowledge,
skills, and attitudes needed for primary care (perhaps even a
fourth year of training); and a training structure that
facilitates greater resident autonomy to foster development
of clinical capability and self-confidence.
Conclusions Important gaps were identified in primary
care training of pediatric residents. These data support
the need to develop more career-focused training.
Journal of Graduate Medical Education, Month 2011 00
Accreditation Council for Graduate Medical Education
(ACGME) requirements.8Questions were developed by
local content experts. Responses were assessed with a
5-point Likert scale that ranged from 1 (not at all well
prepared) to 5 (extremely well prepared). Survey data were
averaged over the 4 years of responses.
A purposive sampling approach resulted in the selection of 8
practices across Colorado, representing diverse experiences
and perspectives of pediatric practice models in the state.
Focus groups were conducted from June 2008 through June
2009 in 6 practices in the Denver metropolitan area
(including 1 large health maintenance organization [HMO]
practice) and 2 practices outside the metropolitan area.
Focus group participants, excluding the facilitators,
included 16 men and 24 women. Four women were
physician assistants and 1 was a nurse practitioner. The rest
of the group was made up of pediatricians with an average
of 18 years in practice, approximately half of whom
received their training in the UCD program. The average
experience of the physician assistants was 7 years and the
nurse practitioner had practiced for 30 years.
The focus groups lasted 60 to 90 minutes and were held at
the practice sites. Two of the coinvestigators moderated the
focus group sessions by following a semistructured interview
guide that used open-ended questions to explore participants’
vision of how they thought current training models prepared
residents for practice. No definition of primary care practice
was provided; all opinions were spontaneous.
Sessions were recorded and transcribed with the
exception of 1 session documented by written notes
recorded independently by 2 of the coinvestigators and then
transcribed. Two coinvestigators (C.K. and A.D.G.)
analyzed transcripts independently by using a grounded
theory approach and uncovering recurrent themes,
hypotheses, and linkages of findings to the literature on
resident training. The transcripts were then hand coded.
Statements were divided into single units including phrases,
sentences, or paragraphs that depicted a single concept.
Using an inductive approach, we grouped these units into
similar conceptual categories until we felt confident of the
dominant themes. Finally, the 2 readers developed
consensus about areas of discrepancy. After 8 practice
interviews, the data were felt to have reached saturation.9
The study protocol was reviewed and approved as
exempt by the Colorado Multiple Institution Review Board.
The results of the survey of recent resident graduates early
in their careers are presented in T A B L E 1. Of the 79
individuals who received the survey, 63 (80%) responded.
Of the respondents, 28 (44%) were practicing primary care
pediatrics. There were no differences between the responses
from those in primary care versus those in other careers
(data not shown).
The focus group data added important qualitative
information that enriched our understanding of the survey
responses. The data clustered into 2 domains: residency
curriculum needs and pediatric practice trends. Each
domain had major themes that were further divided into
categories (T A B L E 2).
Two primary themes emerged related to residency
curriculum: curriculum content and curriculum structure.
The most frequently identified content deficiencies were
mental health (39% of a total of 281 coded comments in the
curriculum content theme), knowledge of practice
management (14%), behavioral medicine (13%),
orthopedics (13%), procedures (7%), basic clinical skills
(7%), communication skills (4%), and phone triage skills
(2%). Illustrative sample comments from these content
domains are presented in the B O X. The content identified as
lacking in the mental health domain included diagnosis and
management of common conditions (depression, attention
deficit and hyperactivity, anxiety). Behavioral medicine
overlaps with mental health but was mentioned often
enough to deserve its own category. This content area
included parenting skills, normal and abnormal behavior
and development, and breast feeding. Details regarding the
need for more orthopedics training in residency mentioned
management of routine injuries requiring casting or
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T A B L E 1
Survey Results From Recent Residency
Graduates Early in Their Careersa
Recognize a sick child
Communicate with colleagues
Communicate with patients and families
Urgent care skills
Intensive care medicine skills
Manage general pediatric problems
Subspecialty knowledge; treatment and referral
Knowledge of use of evidence-based practice
Ability to practice primary care
Knowledge of behavior and development
Knowledge about quality improvement and
Knowledge of practice management
aResults were evaluated on a 5-point Likert scale, ranging from not at all
well prepared (1) to extremely well prepared (5) for their careers.
00 Journal of Graduate Medical Education, Month 2011
splinting, especially sports injuries. Conversation around
the need for greater experience with procedures focused on
simpler procedures except in discussions with the 2 practices
located outside of the Denver metropolitan area. Many of
the procedural skills learned and used in residency were not
used in metropolitan area practices (eg, placement of
umbilical lines in a neonate). There was also concern that
residents are increasingly likely to lack basic clinical skills
(eg, recognition of a child who is in trouble). This was
attributed to perceived lack of autonomy (see below) and
reliance on subspecialists during residency.
Focus group comments about curriculum structure
(T A B L E 2) most frequently addressed lack of continuity of
patient care experiences (27% of 186 coded comments in
the curriculum structure theme) and lack of program
structures that support greater continuity (26%). There was
consensus that true continuity of care is not modeled by
residency continuity clinics. Comments favored a fourth
(additional) year of training (18% of coded comments) or
special accommodation during the third year for residents
intending to practice primary care pediatrics (13%). It
should be noted that the focus group participants were
asked specifically about the possibility of greater career-
oriented flexibility in the third year of residency training.
There was also concern among focus group participants that
residents have decreased autonomy during their training
(8% of coded comments).
The second major domain that emerged from the focus
groups was comments on current practice trends. Themes in
this domain involved both hospital-based and ambulatory
care. The focus group participants noted a change in how
pediatricians in practice participate in hospital care
particularly in the Denver metropolitan area (30% of 161
coded comments in the practice trends domain). Hospital
and well newborn care is usually provided by hospitalists.
However, pediatricians practicing outside of metropolitan
Denver regularly care for hospitalized newborns and are
called to the emergency department for pediatric trauma
cases. Routine primary care is increasingly delivered by
physician’s assistants and other advanced practice nurses
(16% of coded comments in the practice trends domain).
Few metropolitan Denver practices take late night or
weekend telephone calls, and they rarely attend to acute
illnesses after regular office hours (10%). They use a nurse-
staffed telephone triage and advice system linked to a
system of acute-care centers. With regard to the economics
of practice (8%), competition from retail clinics was
mentioned, but was not felt to be a major factor.
The results of 4 years of surveys of recent residency
graduates early in their practice careers and of focus groups
with 8 pediatric practices supplement and confirm
information in the literature.1–7The unique aspect of this
needs assessment is the amplification provided by extensive
focus group discussions. The focus groups also served to
overcome the limitation of using survey data alone, which
might not measure what it was intended to measure. The
focus groups identified deficiencies in residency training as
well as concerns about how the curriculum is structured.
They stated clearly that more emphasis needs to be placed
on training in behavior and development, mental health,
orthopedics, and for practices outside the Denver
metropolitan area, common procedures. It was also evident
in both the survey and focus groups that residents need
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T A B L E 2
Domains, Themes, and Categories
Developed in the Focus Groups
Domain Themes Categories
Content Mental health
Less neonatology, oncology
Structure Lack of continuity
Structure to support
Fourth year of training
Flexibility in training
Hospital care General
Ambulatory careMidlevel providers
Concerns about general
Journal of Graduate Medical Education, Month 2011 00
additional training in practice management. This deficiency
has been identified by others.3,10
The need for development of a stronger mental health
curriculum was emphasized in a survey of recently certified
general pediatricians. In that survey, 62% felt that more
mental health training was needed in residency.2The same
point was made in a policy statement from the American
Academy of Pediatrics, delineating the need for mental
health competencies for pediatric primary care.11The
competencies overlap those of mental health specialists, but
the high prevalence of mental health disorders and
substance abuse in children and adolescents indicates a need
among pediatricians.12,13The policy statement calls for
‘‘innovations in residency training and continuing medical
education activities to increase the knowledge base and skill
level of primary care clinicians.’’11Wissow et al14have
shown that primary care clinicians with training and
experience can deliver evidence-based care for children with
mental health and substance abuse problems.
Behavior and development training is another
previously identified area of content weakness in training
programs.1–3This may reflect in part the disjointed
presentation of this subject area in the 1-month experience
in behavior and development mandated by the ACGME
training requirements.8,15This experience is supplemented
by the resident continuity clinic, but without a focused
approach to allow for deliberate practice, self-confidence in
diagnosing and managing problems of behavior and
development is unlikely to develop.15
Given the frequency of minor orthopedic injuries in
primary care,4,7the emphasis placed by focus group
participants on training in this area is not surprising. It is
estimated that childhood injuries account for greater than
10 million primary care office visits each year, with sports
and overexertion as the leading causes.17Lack of focused
training in this content area has also been recognized and
reported for many years.1,2,18Despite this, hands-on
training, including techniques for a proper musculoskeletal
examination, is lacking.19
Concerns about the structure of the residency
curriculum center on resident continuity clinic and an
apparent lack of opportunities for residents to practice with
enough autonomy to develop capability and self-confidence.
Focus group participants stated that new graduates of
residency training programs seem increasingly tentative
about making clinical decisions. They attributed this lack of
autonomy to shared decision making with subspecialty
fellows and attending physicians, as well as to a decrease in
the frequency of night and weekend call during training.
The tendency to be tentative about making clinical decisions
may also be a manifestation of increasing complexity of
patients in the inpatient setting.20Autonomy during training
is further compromised by fractured faculty supervision. As
a result, individual faculty may not have sufficient exposure
to a given resident to entrust the resident with the
independence of which he or she is capable.21,22
With regard to practice trends, the move to hospital-
based pediatrics in metropolitan areas highlights the need to
emphasize training in ambulatory settings. This is not true,
however, for pediatricians who are likely to practice outside
large metropolitan areas. This would favor an approach in
which learning experiences during residency are
Strategy for Change
These and the results of prior studies1–7beg the question of
why—given the consistency with which deficiencies have
been identified in residency education as preparation for
primary care—there have been few if any changes in the
pediatrics residency curriculum. Epidemiologic data on
which residents and program directors could base
preparation for a career in primary care4–7are available, but
given the experiential nature of resident learning,23,24
nothing can replace experiencing the epidemiology first
hand. A different approach to crafting the elements of
training needs to be developed. The ACGME requirements
specify what must be done in each month of residency for
just 24 of the 33 months.8Seven of these months can be
chosen from a list of subspecialty experiences, with a total
of 16 months that may be structured at the discretion of
programs and residents. A thoughtful, individualized,
career-centered approach applied to this discretionary time
would serve to address the existing gaps (T A B L E 3 ).25
Engaging residents in the development of achievable self-
directed learning goals supervised by a primary care mentor
would enhance career-focused training, allowing residents
to address gaps in their training. Not only can this process
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B O X
QUOTES FROM FOCUS GROUPS
Mental health: ‘‘….We do take care of depression and anxiety now,
which we, I have never been trained for…we are flying by the seat of our
Behavioral medicine: ‘‘….Parenting issues would be another area that
we have to deal with a lot in which basically we had no training.’’
Knowledge of practice management: ‘‘New practitioners need to be
more familiar with billing and the business aspects of private practice.’’
Orthopedics: ‘‘In a week or 2 you could get some fundamentals down
because in some skills I felt like I got enough and then could educate
myself. In sports medicine, I felt like I didn’t even get enough to even
educate myself. I just don’t know where to start.’’
Skills for practice: ‘‘One of the important skills that residents must
master is the ability to differentiate sick from nonsick patients.They need
to know what to do. They need to make a decision instead of thinking,
‘let’s get a consult.’’’
Lack of continuity: ‘‘Continuity isn’t necessarily seeing the patient
again and again, but it’s seeing them today, calling back tomorrow….It’s
dealing with the continuity of the illness that just doesn’t go away.’’
‘‘The focus is so much on urgent issues [in residency], whereas our
world here is a chronic ongoing time-defined longitudinal kind of care.’’
Autonomy: ‘‘I don’t know if it’s not the same anymore, if they get that
same experience [as we once did]….When you get out and you’re
spreading your wings, there’s nothing to catch you. You need to be able
to have the confidence to be able to say: I can do this.’’
00 Journal of Graduate Medical Education, Month 2011
serve to improve training, but it can also set the tone for a
lifetime of self-learning to meet the challenges of primary
care practice. This approach was addressed perfectly by the
following comment: ‘‘In a week or 2 you could get some
fundamentals…and then [I] could educate myself’’ (B O X ). It
is also important to recognize that the division of learning
experiences into month-long blocks is a format better suited
for sampling a variety of topics than in-depth exploration of
a particular topic.16,26Extending some of these experiences
(eg, behavior and development) over a longer period of time
could improve learning.27
These data and available literature support a more
individualized approach to resident training. This could be
done by making use of the discretionary time permitted by
the ACGME program requirements without compromising
the core experience required during residency training. As
emphasized by the Residency Review and Redesign in
Pediatrics Project and now the Initiative for Innovation in
Pediatric Education,28,29residency programs need to replace
some of the time devoted to broad exposure to pediatrics
with time dedicated to preparation for a career within
1 Camp BW, Gitterman B, Headley R, Ball V. Pediatric residency as preparation
for primary care practice. Arch Pediatr Adolesc Med. 1997;151(1):78–83.
2 Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Recently
trained general pediatricians: perspectives on residency training and scope
of practice. Pediatrics. 2009;123(suppl 1):S38–S43.
3 Leslie LK. What can data tell us about the quality and relevance of current
pediatric residency education? Pediatrics. 2009;123(suppl 1):S50–S55.
4 Althouse LA, Du Y, Ham HP. Confirming the validity of the general pediatrics
certification examinations: a practical analysis. J Pediatr. 2009;155(2):155–156.
5 Slora EJ, Thoma KA, Wasserman RC, Pedlow SE, Bocian AB. Patient visits to a
national practice-based research network: comparing pediatric research in
office settings with the national ambulatory medical care survey. Pediatrics.
6 Hewson PH, Anderson PK, Dinning AH, et al. A 12-month profile of
community paediatric consultations in the Barwon region. J Pediatr Child
7 Forrest CB, Glade GB, Baker AE, Bocian AB, Kang M, Starfield B.The pediatric
primary-speciality care interface: how pediatricians refer children and
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8 Accreditation Council for Graduate Medical Education. Program
requirements for residency education in pediatrics. www.acgme.org/
June 17, 2011.
9 Kennedy TJ, Lingard LA. Making sense of grounded theory in medical
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T A B L E 3
Proposed Changes to Address Gaps in Training
Career-centered longitudinal experience
with both a rural and urban option25
Time to master necessary clinical and
management skills for practice
Repetition required for deliberate practice
Can address gaps in both curriculum
content and structure
Monitoring the experience
Develop the learning activities for
Able to address the existing knowledge
gaps: mental health, behavior and
development, orthopedics, practice
Developing a consensus among primary
care experts of the critical training elements
Resident-directed learning goals
Reflection on career goals with self-
assessment of strengths/weaknesses
An individualized curriculum based on the
needs of the resident within the construct
of what training is necessary
Teaching the features of attainable goals
important to the learner
Steps to accomplish
One-on-one mentoring during the
Consistent faculty supervision
Help the resident meet learning goals
Faculty development of mentors
Direct observation of performance
Feedback to aid skill mastery
Faculty development in brief observations
Time to do observations
Longitudinal approach to the required
behavior and development rotation
Create a foundation for all residents in this
Focus on normal and abnormal
development, mental health, parenting
Scheduling logistics: combine required
outpatient rotations to develop a 2–3 month
experience that includes behavior and
Journal of Graduate Medical Education, Month 2011 00
10 Roberts KB, Starr S, DeWitt TG. The University of Massachusetts Medical
Center office-based continuity experience: are we preparing residents for
primary care practice? Pediatrics. 1997;100(4):e2. doi: 10.1542/peds.100.4.e2.
11 Committee on Psychosocial Aspects of Child and Family Health and Task
Force on Mental Health of The American Academy of Pediatrics. The future
of pediatrics: mental health competencies for pediatric primary care [policy
statement]. Pediatrics. 2009;124(1):410–421.
12 US Department of Health and Human Services. Mental health: a report of
the Surgeon General. Rockville, MD: US Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services, National Institutes of Health, National
Institute of Mental Health; 1999.
13 Fox HB, McManus MA, Klein JD, et al. Adolescent medicine training in
pediatric residency programs. Pediatrics. 2010;125(1):165–172.
14 Wissow LS, Gadomski A, Roter D, et al. Improving child and parent mental
health in primary care: a cluster randomized trial of communication skills
training. Pediatrics. 2008;121(2):266–275.
15 Boreman CD, Thomasgard MC, Fernandez SA, Coury DL. Resident training in
developmental/behavioral pediatrics: where do we stand? Clin Pediatr.
16 Ericsson KA. Deliberate practice and the acquisition and maintenance of
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23 Teunissen PW, Scheele F, Scherpbier AJ, et al. How residents learn:
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00 Journal of Graduate Medical Education, Month 2011
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