Pediatrics-Physical Medicine and Rehabilitation

A special agreement exists with the American Board of Physical Medicine and Rehabilitation (ABPMR) whereby an applicant may fulfill the training requirements for certification in pediatrics and physical medicine and rehabilitation by completing five years of combined training. An applicant may take the certifying examination of the ABP in the fifth year of training provided that all pediatric training requirements (except continuity clinics) have been successfully completed.

Download the American Board of Pediatrics and American Board of Physical Medicine and Rehabilitation Combined Residency Training Program Application Form.

Approved Training Programs

Preamble

This document is intended to provide the requirements necessary for a combined training program in pediatrics and PM&R that upon successful completion will result in graduates being eligible for certification in pediatrics and PM&R as well as subspecialty certification in pediatric rehabilitation medicine.  All program requirements in pediatrics and PM&R core residency programs, as published by the Accreditation Council of Graduate Medical Education (ACGME), apply to combined training residencies unless specifically modified in this document.  Because it is unlikely that the ACGME will designate program requirements for these combined training residencies, the training in each new combined residency must be approved by both Boards before residents are recruited.

Objectives of Combined Training

Combined training in pediatrics and PM&R should develop physicians who are fully qualified in both specialties.  Physicians completing this training should be competent pediatricians and physiatrists capable of focusing their professional activity in either discipline; however, the goal of the training is to prepare for a career in pediatric  rehabilitation medicine.  The strengths of the two residencies should complement each other to provide the optimal educational experience.

General Requirements

Program Requirements:
Both categorical training programs must be individually accredited by the ACGME.  Residents may not be recruited for combined training if either program has  probationary status.

Combined training in pediatrics and PM&R must be based in the same institution or academic health care system.  Affiliated programs must be located close enough to facilitate cohesion among the residencies’ house staff, attendance at weekly continuity clinics when scheduled, integrated conferences, and faculty exchanges of curriculum, evaluation, administration, and related matters.

Training Requirements:
The training requirements for credentialing for the certification examination of each Board will be fulfilled by an overall duration of 60 months in the combined residency.  A reduction of 12 months training from that required for the two separate residencies is possible by providing appropriate overlap of training requirements.  The 36-month pediatric training requirement is met by 30 months of pediatric training plus 6 months of pediatric rehabilitation obtained during the 30 months of PM&R training.  Likewise, the 36-month PM&R training requirement is met by 30 months of PM&R training, which includes at least 6 months of pediatric rehabilitation, plus 6 months of rehabilitation related subspecialty months obtained during the 30 months of pediatric training.

The 12 months of training in the R-1 year should be spent in pediatrics.  During the final 48 months, except for one consecutive 12-month period that may be spent in physical medicine and rehabilitation, continuous assignment to one specialty or the other should be not less than 3 or more than 6 months’ duration in any given year.

Training in each discipline must incorporate graded responsibility throughout the training period.

Vacation and family leave should be prorated and consistent with each Board's individual leave policy.

Eligible Resident Requirements:
Residents should enter a combined training residency at the first postgraduate year level.  A resident may enter a combined residency at the second postgraduate year level only if the first residency year was served in a categorical residency in an ACGME-accredited pediatric residency training program. Transitional year training will provide no credit toward the requirements of either Board.  Residents may not enter combined residency training beyond the first postgraduate year level or transfer to another combined residency without prospective approval by both Boards.  A resident transferring from a combined residency to a categorical pediatric or PM&R program should seek specific eligibility information from the appropriate Board.

Program Director:
There must be a single program director with authority and accountability for the operation of the program.  Ideally, this program director is certified in both pediatrics and PM&R or pediatric rehabilitation medicine.  If the program director is certified in solely pediatrics or PM&R, there should be an associate program director from the other specialty to ensure both integration of the residency and supervision in each discipline.  

The program director must administer and maintain an educational environment conducive to educating the combined residents in each of the ACGME competency areas and prepare and submit all information required and requested by the ACGME.  There must be close collaboration between the core programs and the combined training program.  The  combined program director should meet with the program directors of the core pediatric and PM&R programs at least annually to assure that the training of residents is well coordinated and to monitor the progress of each resident.

As a general principle, the training of residents in general pediatrics is the responsibility of the pediatric program director and the training of residents in adult PM&R is the responsibility of the PM&R program director.

Faculty:
There should be an adequate number of faculty members who devote sufficient time to provide leadership to the residency and supervision of the residents.  It is recommended that at least two faculty are certified in pediatric rehabilitation medicine.  

Pediatric faculty must be certified by the American Board of Pediatrics or have acceptable qualifications in pediatrics, as judged by the ACGME and RC for Pediatrics.

PM&R faculty must be certified by the American Board of Physical Medicine and Rehabilitation or have acceptable qualifications in PM&R as judged by the ACGME and RC for PM&R.

Resources:
The program must have access to a service delivery system dedicated to the care of persons with pediatric rehabilitative disorders.  The patient population must be of sufficient size and diversity of pediatric age groups to allow residents to care for an adequate number of patients, in both inpatient and outpatient settings, in all pediatric rehabilitative diagnostic categories.

Resources must include:

• Inpatient pediatric rehabilitation beds
• A designated outpatient clinic or examination area for patients with pediatric rehabilitative disorders
• Transitional services for home-care, community reentry, and return to school
• Equipment, electrodiagnostic services, radiology services laboratory services, and clinical rehabilitation facilities necessary to provide appropriate care to patients with pediatric rehabilitative disorders
• Specialty and subspecialty consulting services essential to the care of patients with pediatric rehabilitative disorders, including:
  • Anesthesiology, diagnostic radiology, emergency medicine, general surgery, medical genetics, neurological surgery, neurology, orthopedic surgery, pathology, plastic surgery, psychiatry and urology

Curricular Requirements:
A clearly described written curriculum that includes skills and competencies specific to pediatric rehabilitation medicine must be distributed to residents and faculty at least annually, in either written or electronic form. The written curriculum for the core training programs should also be distributed, as required by the respective program requirements. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations between the two specialties. 
   
The program must have didactics taught by faculty members, guided reading and a journal club that provide in-depth coverage of the major topics in pediatric rehabilitation medicine, in addition to didactics and conferences in the core programs.

In addition to the curriculum requirements for the core programs, the curriculum must include the following patient care and procedural skills:

• Implementing general pediatric rehabilitative therapeutic management, including early intervention, age-appropriate functional training, programs of therapy, play (avocation), therapeutic exercise, electrical stimulation and other modalities, communication strategies, oral motor interventions, discharge planning, educational and vocational planning, transitional planning, adjustment to disability support and prevention strategies. 
• Incorporating psychological, social and behavioral aspects of pediatric rehabilitative management, including family-centered care.
• Identifying and managing common pediatric rehabilitative medical conditions and complications, including nutrition, bowel management, bladder management, gastroesophageal reflux, skin protection, pulmonary hygiene and protection, sensory impairments, sleep disorders, spasticity, thromboembolism prophylaxis, swallowing dysfunction, seizure management, and behavioral problems.
• Prescribing age-appropriate assistive devices and technology to assist environmental accessibility, including orthotics, prosthetics, wheelchairs and positioning, activities of daily living aids, interfaces and environmental controls, augmentative/alternative communication, and electrical stimulation.
• Rehabilitation management of common pediatric rehabilitation problems, including:
  • Musculoskeletal disorders and trauma, including sports injuries 
  • Cerebral palsy
  • Spinal dysraphism and other congenital anomalies
  • Spinal cord injury
  • Traumatic and other acquired brain injuries
  • Pediatric cancer
  • Neuromuscular disorders
• Competency in selecting and interpreting diagnostic studies commonly ordered in pediatric rehabilitation medicine, including radiographic imaging, laboratory data, genetic testing, urodynamics and electrodiagnostic studies.
• Competency in performing pediatric rehabilitation medicine procedures, including spasticity management. 

Pediatric Rehabilitation Medicine Requirements

Residents should be assigned a faculty advisor who is ideally certified in pediatrics and PM&R or pediatric rehabilitation medicine.

There must  be a specific curriculum for pediatric rehabilitation, which includes 6-12 months of rotations in pediatric rehabilitation medicine.  A minimum of 3 months of both inpatient and outpatient pediatric rehabilitation medicine is required.   Curriculum should also include providing pediatric rehabilitation medicine consultation to other inpatient services, which can occur in conjunction with inpatient pediatric rehabilitation months.

Pediatrics Requirements

The training should be the same as described in the ACGME Program Requirements for Graduate Medical Education for Pediatrics as outlined in this document with the exceptions that follow.

The curriculum should be organized in educational units. An educational unit should be a block (four weeks or one month) or a longitudinal experience. An outpatient educational unit should be a minimum of 32 half-day sessions. An inpatient educational unit should be a minimum of 200 hours.

The specific curriculum elements are detailed in the following chart. 

Program Requirements in General Pediatrics
For Combined Training in Pediatrics-Physical Medicine and Rehabilitation

*Educational Unit = Four weeks or one month block OR outpatient longitudinal experience of 32 half-day sessions OR inpatient longitudinal experience of 200 hours

**Additional Subspecialty includes four units from four different subspecialties from the following list:

An additional three units of single or combined subspecialties are required from the list above or below:

Subspecialty Experience
Educational experiences in the subspecialties must emphasize the competencies and skills needed to practice high-quality general pediatrics in the community. They should be a blend of inpatient and outpatient experiences and prepare residents to participate as team members in the care of patients with chronic and complex disorders.

Pediatric rehabilitation medicine should not be used to fulfill  the subspecialty requirements during the 30 months of general pediatrics training, but one month may be used as an elective. 

Supervisory Responsibility
At least five months of supervisory responsibility must be provided for each resident during the 30 months of pediatrics training and must include experience leading an inpatient team. 

Continuity Clinic
There must be a minimum of 108 half-day sessions of a longitudinal outpatient pediatric experience in a continuity clinic. The patients should include those previously cared for in the hospital, well children of various ages, and children of various ages with special healthcare needs and chronic conditions, especially those requiring expertise in physical medicine and rehabilitation. Residents must have a longitudinal general pediatrics outpatient experience in a setting that provides a medical home for the spectrum of pediatric patients and must care for a panel of patients who identify the resident as their primary care provider. It is desirable that residents also experience an equivalent of a two-year longitudinal pediatric rehabilitation clinic during their residency.   

The medical home model of care must focus on wellness and prevention, coordination of care, longitudinal management of children with special healthcare needs, and provide a patient and family-centered approach to care.

Additional Experiences
To fulfill the additional six months of pediatrics training required in the combined program, the focus of the curriculum should be on providing experiences that will help residents be better prepared for the next step in their career after residency. The curriculum might include additional subspecialty experiences not already used to fulfill the core subspecialty requirement in pediatrics, additional supervisory experiences on an inpatient pediatric service, or other electives.  No more than one month of pediatric rehabilitation may be chosen as an elective. 

Physical Medicine and Rehabilitation Requirements

The 36-months of PM&R training requirement is met by 30 months of PM&R training plus six months credit for pediatric subspecialty rotations whose focus is felt to have considerable overlap with the clinical skills necessary for the practice of pediatric rehabilitation medicine.  The following are a list of pediatric subspecialty rotations that can count towards the 6 months of PM&R training requirements: child abuse, developmental/behavioral pediatrics, genetics, hematology/oncology, hospice/palliative care, neurology, neurodevelopmental disabilities, orthopedics, pediatric rehabilitation medicine, psychiatry, rheumatology, or sports medicine.

The 30 months of PM&R training must include the following requirements:

• A minimum of 12 months of inpatient training (adult or pediatric) with an average daily patient load of eight patients over the 12 month inpatient experience.  
• A minimum of 12 months of outpatient experience (adult or pediatric), excluding time spent in EMG training
• A minimum of 3 months of pediatric rehabilitation outpatient experience
• A minimum of 3 months of pediatric rehabilitation inpatient experience 
• A maximum of 12 months of pediatric rehabilitation experience 

The following segments of training in PM&R are also required: adequate training to achieve basic qualifications in electromyography and electrodiagnosis, and opportunities to achieve understanding of special aspects of rehabilitation of patients in geriatric age-groups.

Evaluation

All evaluation requirements as outlined in the program requirements for each specialty must be observed.

Residents:

The residents should be evaluated by the clinical competency committees of the core program semiannually and reported to the ACGME.  The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision according to the requirements of the respective RC’s. Residents should be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive competence and professional growth. Program directors for pediatrics and PM&R must advise the combined program director at least annually as to the resident’s progress towards promotion and immediately if remediation or dismissal are being considered.

A separate clinical competency committee, specific to pediatric rehabilitation medicine, should be convened during years 4 and 5 for reporting of the pediatric rehabilitation medicine milestones to the ACGME.

Faculty Evaluation:

• At least annually, the program must evaluate the pediatric rehabilitation faculty performance as it relates to the educational program. 
• These evaluations should include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism and scholarly activities.
• Faculty evaluation must be kept confidential.

Program Evaluation and Improvement:

• The combined program director must appoint a Program Evaluation Committee for the combined program.
• The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written, annual program evaluation.
• The PEC must prepare a written plan of action to document initiatives to improve performance in one or more areas, as well as document how they will be measured and monitored.  

Certification

The residents in a combined residency must satisfactorily complete the specific credentialing requirements of each Board to be eligible for the examination of the Board.  Clinical competence must be verified by the respective program directors.  *Upon successful completion of all requirements of the combined residency, the candidate is qualified to take  the ABP, the ABPM&R certification examinations and the PRM subspecialty certification examination.  (Certification in PM&R must be obtained prior to subspecialty certification in PRM.)   The candidate will be certified by each Board upon successful completion of its certifying examination. It is the candidate's responsibility to complete the examination process in each specialty. 

* This policy will go into effect with the 2020 General Pediatric Certifying Examination.  For examinations given before 2020, fourth year trainees may take the general pediatrics examination in the fall of their fifth year of combined training if they have successfully completed all pediatric training requirements.     

9/96   Approved by American Board of Pediatrics
2/97   Approved by American Board of Physical Medicine and Rehabilitation
4/97
5/98
7/98
12/01
10/2017 Approved by American Board of Pediatrics 
1/2018   Approved by American Board of Physical Medicine and Rehabilitation