Lieberman and Hilliard showed that Canadian paediatricians felt inadequately trained in several areas, including gynecology, child psychiatry, behavioural paediatrics, surgical subspecialties, adolescent medicine, dermatology, nutrition, allergy and immunology, metabolics and genetics. Determining the reasons why these areas of deficiency arise was the primary goal of our study. Our findings point to both resident perceptions, as well as insufficient emphasis by training programs as potential explanations for these deficiencies.
Reassuringly, trainees were satisfied with their current training and felt they would be adequately prepared for independent practice. This is similar to the findings of Lieberman and Hilliard (2
), who found that 96% of respondents felt they were adequately or well trained. However, we demonstrated that during training, residents place lesser importance on nine of the 10 areas identified in Lieberman and Hilliard’s study as deficient in future practicing paediatricians. It is possible that during training, residents may not appreciate the practical significance of these topics until after graduation.
It is also possible that training programs themselves place less emphasis on these topics. More than 40% of residents viewed their programs as placing less importance on all 10 areas deemed deficient by practicing paediatricians. There are several reasons why training programs may place less emphasis on these topics. There may be a lack of awareness that these are topics are important for future clinical practice. It may also be due to the absence of established subspecialty clinical programs at some institutions or a lack of available teachers. Programs may be able to improve knowledge in these areas by encouraging electives at other institutions, encouraging independent reading on these topics or presenting these topics as academic half days.
We found significant discrepancies in certain areas that were deemed important to residents, but were perceived as being less important by their training programs. These discrepancies may be the initial seed that has skewed resident interest and motivation in these topics in the first place. Programs may be giving the perception that these areas are not worth focusing on, and perhaps if training programs were to actively promote these topics, residents may be encouraged to place more emphasis on them during their training.
How then, should programs incorporate all of these areas into already full curricula? One option may be to extend the length of training; however, only 20% of the respondent’s in Lieberman and Hilliard’s study (3
) felt that paediatrics training should be extended to five years. Programs were seen as placing more importance on general surgery and neonatology compared with residents themselves. This may mean that residents feel programs place more emphasis than is needed on these topics and may indicate areas that could be adjusted to accommodate other ‘deficient’ areas, although qualitative focus group research would help to better clarify this.
Although most residents feel the CanMEDS roles are important, one-quarter of residents did not place a great deal of importance in them. Specifically, residents placed less importance in the medical aspects of palliative care (medical expert role) and managing an efficient office practice (manager role), which were two of the three roles that were deficient in practicing physicians. Again, a lack of importance felt by residents in these areas during training is likely contributing to deficiencies on graduation. Similarly, residents felt their programs placed less emphasis on three of the CanMEDS roles that were identified as deficient in practicing paediatricians. Incorporating these roles more effectively into the paediatric curriculum may help to promote their importance, making residents more inclined to realize their impact on future practice.
Overall, PDs views on the importance of different areas of subspecialty training mirrored residents’ views At least 50% of PDs rated seven topics identified as being deficient in newly practicing paediatricians by Lieberman and Hillard as less important to resident learning. It would be interesting to know the representation of these topics in paediatric residency curriculums in Canada, and whether this is representative of PDs views on their importance. As PDs have a direct role-model influence on residents, the effects that their opinions have on resident education is substantial.
The main limitation of our study was the low response rate, and this needs to be taken into account when interpreting the data. Internet surveys are relatively new and have many potential advantages such as easier data analysis, faster response time and less paper waste. Unfortunately, they tend to produce significantly lower response rates than traditional paper versions. Several recent studies comparing internet and paper surveys found internet response rates vary anywhere between 11% and 58% (14
). Thus, our response rates still fall well within the expected range for this type of survey. Our study could also have been strengthened by subdividing responses accordign to PGY, thereby allowing us to determine whether more senior residents had a different viewpoint on what should be emphasized in their training; this was not possible due to the low response rate. Additionally, it would have been ideal to compare resident perceptions of importance with external measures of resident knowledge, such as performance on the American Board of Pediatrics in-training examination or the RCPSC examination in pediatrics, to determine whether in fact, knowledge deficiencies were found in certain areas. However, this was beyond the scope of our study.
Thus, this perceived lack of importance felt by both residents and programs in various subspecialites and CanMEDS roles may contribute to deficiencies in newly graduated paediatricians. Qualitative research may be needed to understand the reasons why; knowing these reasons would better assist us in determining how we may alter the attitudes and training toward these future areas of deficiency. Promotion of these topics by training programs may also help to emphasize these areas, and better prepare residents for future practice.