Compared to previous studies of community pediatrics educational interventions, which have reported evaluations of one topic or one discrete block of time,,10,11,13,14
the quasi-experimental design of the evaluation of the CHAT curriculum allowed for the identification of favorable changes in residents' attitudes toward social, community, and environmental determinants of child health; increased levels of exposure in community and child health advocacy activities; and acquisition of skills to address the prevention and management of many relevant pediatric chronic diseases of the 21st Century. These favorable changes were accomplished by providing longitudinal experiences seamlessly integrated into 3 years of residency training without impacting the acquisition of traditional clinical knowledge.
Residents who participated in the CHAT curriculum maintained more positive attitudes toward community pediatrics, child advocacy, and caring for vulnerable populations than the categorical residents, whose attitudes significantly decreased. These CHAT residents indicated that topics such as child welfare, community violence, accessing community resources for underserved children and children with special health care needs, and providing preventive health education to various community groups such as schools and child care facilities were important to the primary care of children. These results are critical, considering the increasing prevalence of childhood diseases such as asthma, obesity, and mental health issues and other chronic conditions that are largely shaped by social, community, and environmental factors that create challenges to adequate promotion of health and treatment of disease ,15–18
and that require a population-level, public health approach to address successfully. These results also imply that without the frequent reinforcement of these topics throughout residency, pediatric residents' attitudes toward these topics may decrease, especially as the competing clinical priorities occupy more of their time.
As for the knowledge portion of our evaluation survey, categorical and CHAT residents achieved significant increases in community pediatrics knowledge during residency. We expected both groups to do well with the knowledge questions, because we were aiming for proficiency in basic community pediatrics topics, rather than specialized knowledge about advanced public health topics. The fact that both groups achieved statistically significant increases in community pediatrics knowledge also indicates the spill-over effect the CHAT program had on the categorical curriculum through increased noon conferences and exposure to these topics during community pediatrics intern and child advocacy PL-3 rotations for all residents.
The importance attributed to broad determinants of children's health was mirrored by resident changes in exposure and self-perceived levels of skills to address topics such as community violence and working with community agencies to promote health. Our results suggest that residents who were trained in the CHAT curriculum reported higher levels of exposure and levels of skills to engage in community and child health advocacy experiences to impact and modify the social, community, and environmental determinants of health. While it might be intuitive that the CHAT residents would by definition have greater exposure to community topics, we wanted to be sure to account for community experiences the categorical residents might have sought on their own. The skills reported by the CHAT residents included specific, demonstrable abilities to improve the health landscape of children and families. For example, residents were able to demonstrate participation in community meetings, contacting schools to advocate for services on their patients' behalf; participation in health-promoting community activities such as leading a parent education curriculum; and providing technical assistance for implementation of developmental screening in a community child care facility. These were services parents and community partners viewed as value-added through the participation of a pediatrician-expert outside of the clinic.
Residents were responsive to the social determinants of health through their increased participation in community and child health advocacy activities. These changes have important implications for graduate behaviors related to patient care, as residents who have changes in self-reported comfort levels in the context of a larger educational intervention are more likely to change their behaviors in patient care19
and exposure to partnering with communities in improving and advocating for child health are more likely to continue these behaviors once in practice.20
While we found that residents who participated in the CHAT curriculum entered primary care at higher rates than residents who did not participate, our experience has important implications for subspecialty-oriented residents. Because subspecialty clinicians frequently work closely with large numbers of children with special health needs, it is imperative that they are familiar with community resources and strategies.
As part of the CHAT program mission, we were committed to training pediatric residents from diverse backgrounds. We observed that residents from underrepresented minority backgrounds were drawn to the CHAT mission and curriculum and often excelled in their longitudinal projects, exhibiting a passion for and dedication to the public health, population approach to clinical medicine, which differs greatly from the hospital-based, subspecialty-oriented focus of traditional residency training. All CHAT graduates passed their ABP-certifying examination on the first try, despite varying levels of achievement on the United States Medical Licensing Examinations or the In-Training Examinations (data not shown). While participation in the CHAT program likely led to some knowledge acquisition from our didactic curriculum, we believe the CHAT program gave these residents added confidence, and the identification of different clinical strengths during residency allowed them to do better on the certifying examination.
Our study has several implications. First, it is possible to have a positive effect in a critical, evidence-based area of child health, namely population-level strategies for the approach to determinants of health development. Given this emerging body of evidence, pediatric residency programs should consider inclusion of a public health approach to addressing problems such as obesity, oral health, and special health care needs in children. One of the critical elements for success in this is to have faculty trained in public health or enough faculty development to support junior faculty to pursue this line of curricular development. The UCLA CHAT program was fortunate to have 6 faculty members dually trained in pediatrics and public health at the program's inception. Strategies to support residency programs without public health-trained faculty or a nearby school of public health from which to draw experts should be explored.
Our study has several limitations. First, residents who participated in the public health model of training may have had more interest in these particular topics and training experiences. However, incoming residents (PL-1) in the new CHAT program were not significantly different from those in the categorical program in community pediatrics exposure, attitudes, and beliefs. Second, our evaluation was limited to residents' self-reports, as our study did not have the resources to validate residents' reports of knowledge and skills through observed structured clinical examinations or other observational methods.