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Improving Training to Promote Lifelong Learning

Monday, March 12, 2018 - 14:45

Dr. Pamela Londres confers with Dr. Christian Lawrence.The journey of continuous learning for pediatricians begins during residency, when they are gaining the competencies to provide medical care for children without direct supervision. During these years of training, they are guided by pediatric program directors who, along with other pediatric faculty members, monitor their progress and help them identify and fill gaps in their knowledge and skills.

Although residents are often unaware of the connection, it is during training that the ABP begins supporting their continuous efforts to provide outstanding health care for children throughout their careers. The ABP partners with program directors in both residency and fellowship programs and with affiliated organizations — including the Association of Pediatric Program Directors (APPD) and the Accreditation Council for Graduate Medical Education (ACGME) — to set standards for specific competencies and prepare trainees for their initial certification exam.


The ABP’s annual in-training exams (ITEs) help program directors measure how well their training program is performing regarding medical knowledge, and how well individual trainees are progressing. Residents take an ITE after the first two weeks of residency, and again early in their second, third and, sometimes, fourth years.

“The in-training exam is an annual opportunity for residents to self-assess their knowledge and see how they compare to residents around the country,” says Franklin Trimm, MD, Professor and Vice Chair of Pediatrics and Director, Pediatric Residency Program, University of South Alabama Children’s and Women’s Hospital. Dr. Trimm also serves as President of the Association of Pediatric Program Directors (APPD). “Their score sets the stage for what can be very meaningful conversations between a resident and their program director about what is working and what they might need to do differently.”

Kenya McNeal-Trice, MD, Associate Professor of Pediatrics and Pediatric Residency Program Director at the University of North Carolina School of Medicine, says she meets with all trainees twice a year to review how well they are filling knowledge gaps identified in the ITE.

“We try to individualize our curriculum, so our trainees will be successful when they take their initial general pediatrics certification exam,” she says.


Readiness to practice involves much more than knowledge, however. At the end of training, program directors must attest to trainees’ clinical competence. To help, the ABP provides program directors various resources to help trainees master the ACGME’s competency standards.

“Each year, we assess the resident’s professionalism, patient care skills, communication skills, and all the ACGME’s core competencies — not only medical knowledge,” says Ann Burke, MD, Professor of Pediatrics, Pediatric Residency Director and Vice Chair for Pediatric Education at Boonshoft School of Medicine at Wright State University. Dr. Burke also is the 2018 Chair of the ABP Board of Directors.

“We rely on program directors to tell us when a trainee is clinically competent. Only then can they sit for their initial certification exam,” says Gail McGuinness, MD, ABP Executive Vice President, who led the ABP’s Department of Credentialing and Examination Administration for 15 years until her retirement Dec. 31, 2017.


The ABP also has been closely involved in establishing milestones, which are narrative descriptions of behaviors for each of the competencies along a continuum of development, ranging from novice (an early medical student) to a master clinician who is years into practice. Program directors use these descriptions to measure a trainee’s progress.

Victoria Norwood, MD, Subspecialty Program Director for Nephrology at the University of Virginia (UVA) School of Medicine, says milestones help her subspecialty trainees see their progress toward a specific goal.

“I find the milestones to be a much more specific way for faculty to think about trainees and their strengths and weaknesses. And it provides a real framework and granularity of detail for me to discuss those performance issues with trainees in a way that was not really available before,” says Dr. Norwood, who oversees all UVA educational programs in pediatrics as Vice Chair for Academic Affairs.


In addition to milestones, the ABP’s Education and Training Committee (ETC) created a primer to help program directors accurately assess residents and fellows in all six competencies.

“The science of assessment in medical education has really advanced in the last 15 or 20 years,” says Richard Shugerman, MD, Chair of the ETC and Vice-Chair for Faculty Development and Professor of Pediatrics at Seattle Children’s Hospital, University of Washington (UW). “The primer is a terrific way of helping program directors keep up with that science.”

Assessment in Graduate Medical Education: A Primer for Pediatric Program Directors is available on this website in the Program Directors section.


The critical competency of professionalism can be one of the most difficult to define and measure. To support program directors, the ABP’s ETC recently updated Teaching, Promoting and Assessing Professionalism Across the Continuum: A Medical Educator’s Guide, which also is available on this website in the Program Directors section.

Dr. Trimm, an ETC member and an editor of the guide, says studies have shown that if professionalism issues are not addressed early in training, then doctors are at greater risk of exhibiting poor professionalism throughout their careers.

The revised professionalism guide addresses not just residents, but also medical students and fellows. It includes new topics, such as digital professionalism and how to use social media in ways that promote child well-being while maintaining professionalism.

UW’s Dr. Shugerman says the guide is “structured for program directors as a teaching tool that they can use to put together learning sessions with residents in a variety of different formats, including case studies with questions. You can take just one case study at a time, depending on how that fits your needs.”

UVA’s Dr. Norwood says the Professionalism Guide is helpful when working with trainees who may not understand why something they have done is unprofessional. “It provides a very solid, real-life way to counsel anyone who’s having troubles in that area,” she says. “It’s nice to be able to turn to the guide as a program director advisor and say, ‘This isn’t just my opinion.’”


Program directors also plant the seeds for continuous learning, says Dr. Norwood. She says it is the program director’s role to help bring trainees into the world of certification and encourage them to maintain their certification throughout their career.

“We remind everyone that providing the best care for children for the lifetime of your career mandates that you stay upto-date in relevant practices — and that means continuous learning,” she says.

She uses a fellows’ forum to go over the processes for reaching subspecialty certification, then bridging into MOC. She holds similar forums for faculty and encourages them to guide trainees to follow ABP MOC standards for their quality improvement projects so that the residents can bank credits to claim during their first five-year MOC cycle. Faculty members also can claim MOC Part 4 credit for projects they work on with trainees.

UNC’s Dr. McNeal-Trice agrees. “The learning continuum keeps going once they finish residency training and are working in an independent practice or in specialty fellowship training. We get our trainees used to continuous learning and improvement while they’re in training, so it becomes a normal part of their routine once they are in independent practice,” she says.

Suzanne Woods, MD, ABP Vice President of Credentialing and Initial Certification, says, “We need to ensure that trainees understand how critical it is to keep learning throughout their careers.” Dr. Woods, who joined the ABP staff Jan. 1, 2018, was previously a program director at Duke University Medical School. “When trainees are engaged with the ABP early on, they learn how instrumental the Board can be in helping them stay on top of medical advances and best practices.”