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Old Guidelines for Combined Training in Pediatrics and Medical Genetics

Preamble

This document is intended to provide educational guidance to program directors in pediatrics and medical genetics. All program requirements in both specialties, as described in the Directory of Graduate Medical Education published by the ACGME, apply to combined residencies unless specifically modified in this document. Because it is unlikely that the RCs in both specialties will write 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 medical genetics should develop physicians who are fully qualified in both specialties. Physicians completing this training should be competent pediatricians and medical geneticists capable of focusing their professional activity in either discipline. It is anticipated that many trainees will develop careers focused on genetic diseases in children. The strengths of the two residencies should complement each other to provide the optimal educational experience.

 

General Requirements

The Residency Candidate

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 pediatrics in the same academic health center. Transitional year training will provide no credit toward the requirements of either Board. Residents may not enter combined residency training and receive credit beyond the first postgraduate year level, nor may a resident transfer to another combined residency without prospective approval by both Boards. A resident transferring from a combined residency to a categorical pediatric or medical genetics program should seek specific eligibility information from the appropriate Board.

Vacations, leave, and meeting time will be shared equally by both training residencies. Family leave should be prorated and consistent with each Board's individual leave policy

Characteristics of Eligible Combined Residencies

Both training residencies must be accredited by the ACGME. Residents may not be recruited for combined training if either categorical program has provisional or probationary status. Combined training in pediatrics/medical genetics must be based in the same institution or academic health care system. Affiliated residencies 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 60 months in the combined residency. A reduction of pediatric residency training by 6 months is made possible by medical genetic training experiences that provide a pediatric focus. The integration of training after the R-1 year will increase the exposure of pediatric categorical residents to medical genetics via the combined residency trainees. The working relationships developed among categorical and combined residency trainees will facilitate communication between the two specialties.

At least 10 months of training in the R-1 year should be spent in pediatrics. During the final 48 months, except for a block of training spent in medical genetics equivalent to the longest block of training in pediatrics, 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.

Faculty

The combined residency must be coordinated by a designated full-time director or codirectors who can devote substantial time and effort to the educational program. If a single combined residency training director is appointed, an associate director from the other specialty must be designated to ensure both integration of the residency and supervision in each discipline. An exception to this requirement would be a single director who is certified in both specialties and has an academic appointment in each department. The directors from both specialties must document meetings with each other at least quarterly to monitor the success of the residency and the progress of each resident.

Well-established communication must occur between the program directors of each discipline, particularly in those areas where the basic concepts in both specialties overlap, to assure that the training of residents is well coordinated.

As a general principle, the training of residents in pediatrics is the responsibility of the pediatric faculty and the training of residents in medical genetics is the responsibility of the medical genetics 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 some faculty members have completed combined training in these two specialties. Since each component of the residency must be accredited by its respective discipline, the faculty must meet the requirements for their specialty.

Pediatric faculty must be certified by the American Board of Pediatrics or have equivalent qualifications in pediatrics.

Medical Genetics faculty must be certified by the American Board of Medical Genetics or have equivalent qualifications in medical genetics.

Curricular Requirements

A clearly described written curriculum must be available for residents, faculty, and both Review Committees. The curricular components must conform to the goals and objectives in the Program Requirements for accreditation in pediatrics and medical genetics. There must be 30 months of training in each specialty. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the two specialties should be avoided. Periodic review of the residency curriculum must be performed by the program directors of both departments with consultation with residents and faculty from both departments.

Joint educational conferences involving residents from pediatrics and medical genetics are desirable and should specifically include the participation of all residents in the combined training residency.

Periodic Evaluations

Both Boards require the annual tracking evaluations to be completed at the end of each training year.

Periodic evaluation of the educational progress of the resident by the program directors in both specialties is required as specified by each specialty. The evaluations should be discussed with the resident at least annually, signed by the resident, and must be kept on file and available for review.

 

Pediatric Requirements

The development of the residents' skills in pediatrics will be fostered by rotations on general pediatric services, both inpatient and outpatient, with exposure to a wide spectrum of disease. The resident must be exposed to pathologic conditions ranging from mild to severe illness, including life-threatening conditions requiring critical care. Fifty percent of clinical training must be in ambulatory settings. The pediatric patient population served must encompass adequate numbers and extend from the newborn (including premature infants) through childhood and adolescence.

The training should be the same as described in the Program Requirements of the Review Committee (RC) for Pediatrics with the exceptions that follow.

Thirty months of training must be in pediatrics; the additional 6 months of credit is recognized through 6 months of medical genetics training.

Ambulatory Service

In keeping with the commitment to primary and comprehensive care, the 5-year combined residency must provide that 50% of the pediatric experience be ambulatory. This may include all assignments in continuity clinic, acute illness and emergency department, and community-based experiences, as well as the ambulatory portion of the normal newborn, subspecialty, behavior/development, and adolescent experiences.

Emergency and Acute Illness Experience

The experience in emergency and acute illness must constitute a minimum of 4 months. Two of these months should be in emergency medicine; at least 1 of these months must be a block rotation in an emergency department that serves as the receiving point for EMS transport and ambulance traffic and is the access point for seriously injured and acutely ill pediatric patients in the service area.

Inpatient Experience

General inpatient pediatrics must constitute at least 5 months of a resident's overall experience, exclusive of intensive care rotations. Intensive care experiences must be for a minimum of 4 and a maximum of 6 months and must include at least 3 block-months of neonatal intensive care (Level II or III) and 1 block-month of pediatric intensive care. At least 2 months of supervisory experience must occur on inpatient services.

Normal Newborn Nursery

At least 1 month must be spent in the care of the normal newborn infant.

Subspecialty Experience

Time spent in training in the pediatric subspecialties, excluding adolescent medicine and intensive care experiences, must be a minimum of 6 months. The required and desirable subspecialty experience should conform to the RC Program Requirements for categorical pediatric training.

Continuity Clinic

There must be at least weekly experience in a continuity clinic throughout the pediatric months of training. The patients should include those cared for in the hospital, well children of various ages, and children of various ages with chronic diseases and developmental problems. It is desirable that these experiences continue every other week during genetics training.

Supervisory Responsibility

At least 5 months of supervisory responsibility must be provided for each resident during the 30 months of training in pediatrics. The supervisory responsibilities must involve both inpatient and outpatient experience.

Adolescent Medicine

There must be a structured educational experience to train residents in the medical and psychosocial problems of the adolescent. This rotation must be for at least 1 month. During this time, experience in adolescent gynecology should be available.

Behavioral/Developmental Pediatrics

At least 1 month of a structured, focused experience in behavioral/developmental pediatrics must be provided. The experience must be supervised by faculty with training and/or experience in the behavioral/developmental aspects of pediatrics.

 

Medical Genetics Requirements

The development of the resident's skills in medical genetics will be fostered by experiences that prepare the residents to provide comprehensive diagnostic, management, and genetic counseling services for patients with genetic, or possibly genetic, disorders and to plan and coordinate large- scale screening programs for inborn errors of metabolism, hemoglobinopathies, chromosome abnormalities, neural tube defects, and other genetically influenced conditions. Upon completion of training, residents will be able to: (a) diagnose and manage genetic disorders; (b) provide patient and family counseling; (c) use their knowledge of heterogeneity, variability, and natural history of genetic disorders in patient-care decision making; (d) elicit and interpret individual and family medical histories; (e) interpret clinical genetic and specialized laboratory testing information; (f) explain the causes and natural history of genetic disorders and genetic risk assessment; and (g) interact with other health-care professionals in the provision of services for patients with genetically influenced disorders.

The training should be the same as described in the Program Requirements of the Review Committee for Medical Genetics with the exception that 30 months of training must be in medical genetics.

Patient Population

Residents must have the opportunity to care for a number of patients and families sufficient to permit them to develop an understanding of the wide variety of medical genetic problems, including Mendelian disorders, inborn errors of metabolism, diseases of chromosome number and structure, multifactorial disorders, syndromes, congenital malformations, other birth defects, and other genetically influenced conditions. Typically, this will mean that programs will care for at least 100 different patients or families per year for each resident. These patients or families must be seen in outpatient and inpatient settings. As medical genetics involves families and individuals of all ages, residents must be competent to work with both adults and children and must have an opportunity to gain an understanding of family dynamics as they relate to issues of diagnosis, counseling and management.

Correlation of Laboratory and Clinical Experience

Clinical biochemical genetic, molecular genetic, and cytogenetic laboratories must be integral components of each program, and residents must have regular opportunities to develop their abilities to understand and critically interpret laboratory data. Residents should develop an understanding of the appropriate use of laboratories during diagnosis, counseling, and management of patients with genetic disorders. Toward this end, resident education must include ongoing participation in the working conferences of laboratories as well as discussions of laboratory data during other clinical conferences.

Other Health-Care Professionals

Residents must have regular opportunities to work with genetic counselors, nurses, nutritionists, and other health-care professionals who are involved in the provision of clinical medical genetics services. Because of the complex nature and multiple system involvement of genetic disorders, residents must be exposed to multidisciplinary and interdisciplinary models during the residency and must be proficient in organizing teams of health-care professional to provide the necessary resources for their patients.

Responsibilities for Patient Care Including Continuity Care Experiences

The development of mature clinical judgment requires that residents, properly supervised, be given responsibility for patient care commensurate with their ability. This can be achieved only if the resident is involved in the decision-making process and in the continuity of patient care. Residents must be given the responsibility for direct patient care in all settings, including planning and management, both diagnostic and therapeutic, subject to review and approval by the attending physician. Continuity clinic experiences are recommended throughout the 30-month training period.

Basic Sciences

Each resident must participate formally through lectures or other didactic sessions in the equivalent of a 1-year graduate-level course in basic, human, and medical genetics, including but not limited to population and quantitative genetics, Mendelian and non-Mendelian genetics, cytogenetics, biochemical genetics, and molecular genetics. Research seminars should be part of the training experience but should not be considered an acceptable alternative to this basic science didactic component.

Clinical Conferences

Clinical teaching conferences must be organized by the faculty for the residents, and attendance by the residents and the faculty must be documented. These conferences must be distinct from the basic science lectures and didactic sessions. Clinical teaching conferences may include formal didactic sessions on clinical laboratory topics covered on medical genetic rounds, journal clubs, and follow-up conferences for genetic clinics. In combined training residencies in pediatrics and medical genetics, integration of the genetic clinical conferences with involvement of the pediatric generalists and subspecialists is urged.

 

Credentialing

The residents in a combined training 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 both department chairs/program directors. Lacking this verification, the resident must satisfactorily complete 3 years of training in pediatrics or 4 years training in medical genetics to qualify for the examination in the respective specialty.

Upon successful completion of all requirements of the combined residency, the candidate is qualified to take either or both the ABP and the ABMGG certification examinations. A candidate may apply for the certifying examination in general pediatrics in his/her fourth year of combined residency and take the examination in the fall of their fifth year if, by that time, they have successfully completed all pediatric training requirements except for continuity clinic. The candidate will be certified by each Board upon successful completion of its certifying examination. Certification in one specialty will not be contingent upon certification in the other. It is the candidate's responsibility to complete the examination process in each specialty.

9/96 Approved by American Board of Pediatrics
10/96 Approved by American Board of Medical Genetics and Genomics
4/97
11/97
7/98
12/01