The evolution of pediatric residency training over the past century has consistently bent toward reduced hours in the hospital and more time in ambulatory settings. The original “house staff” model founded in Baltimore at the turn of the 20th century by William Osler literally had post–medical school graduates living in the hospital as residents and caring for patients nearly 24-7 for years. By the middle of the 20th century, most pediatric residents took call every other night, which eventually eased to “q3” and then “q4” call. Finally, the Accreditation Council for Graduate Medical Education (ACGME) adopted the 80-hour workweek for all residents of all specialties in 2003. Along with decreasing the amount of work hours, the location of care for pediatric residents has changed from primarily inpatient and intensive care units to ambulatory settings. Upcoming changes to pediatric residency training will include an even greater reduction of inpatient and intensive care time.
So what does all of this mean for graduates and newly practicing pediatricians? A brief report in this month’s Pediatrics by Gottschlich et al. (10.1542/peds.2023-063764) provides some sobering answers. Looking at data from the 2015–2022 AAP Annual Survey of Graduating Residents, fewer and fewer pediatric residency graduates feel prepared for their post-graduate first job—no matter what the location. Most concerning, only 42% of graduates in primary care felt that they were prepared, down from 69% less than 10 years ago. Significant declines were also seen in those entering a subspecialty fellowship (dropping from 79% to 66%) and those starting hospitalist work (down from 87% to 79%). Overall, it does seem like we have a problem.
The biggest question is what is the solution? Do we need 4 years of residency? Do we need to change completely from a time-limited system to a competency-based system (where some people will take 2 years and others 4)? Accept that residency is just a start to a lifelong learning process and no one is really ready for their first job? I am not sure I have any great answers, but now is the time to really figure out the best way to prepare the next generation of pediatricians. With fewer and fewer children requiring hospital care and more and more children having mental health issues, the proposed residency changes make sense, but volume and exposure to many conditions do matter. Assuring all graduates leave competent and prepared for their next step is an imperative for all educators, and we are going to have to come up with some answers to all these questions soon in order to maintain high quality pediatric care by well-trained, competent pediatricians.
