Drs. Fisch, Young, Bromberg, Kraft, and Roberts have disclosed no relevant financial relationships.
Address correspondence to: Kenneth B. Roberts, MD, 3005 Bramblewood Dr., Mebane, NC 27302; email: Kenrobertsmd@gmail.com.
Although a century has passed since the Flexner Report to the Carnegie Commission was presented, its effect still resounds, having been the catalyst that shifted the responsibility for medical education from community-based physicians to professors in universities. The primary clinical setting for training was also affected, moving from community offices to hospitals.
Flexner proposed that a clinical professor should “develop, preferably in close connection with the hospital, a consulting practice, assured thus that his time will not be sacrificed to trivial ailments.”1
The words “sacrificed” and “trivial” created a divisive “town-gown” distinction that grew during the 20th century, particularly as specialization increased. During the last few decades, however, as generalism and primary care have received increased attention, practitioners have been “rediscovered” as teachers for medical students and residents.
Recent articles in this journal2–4 have addressed the contributions of office-based practitioners to pediatric education. This article introduces you to four pediatrician role models, individuals who, through their activities, have demonstrated the enormous contribution community pediatricians can make to academic programs.
- Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching, 1910.
- Nagappan S, Doyne EO, Roberts K, Dewitt TG. Pediatric education in office settings. Pediatr Ann. 2010;39(2):67–71. doi:10.3928/00904481-20100120-05 [CrossRef]
- Allevi AM, Lane JL. Microskills in office teaching. Pediatr Ann. 2010;39(2):72–77. doi:10.3928/00904481-20100120-06 [CrossRef]
- Benuck I. Enhancing Your Pediatric Practice. Pediatr Ann. 2010;39(6):328, 331. doi:10.3928/00904481-20100521-02 [CrossRef]
- American Academy of Council Pediatrics, on Community Pediatrics. Starter Kit for Community Preceptors. practice.aap.org/content.aspx?aid=1711. Accessed Oct. 26, 2011.
- Accreditation Council for Graduate Medical Education. General Competencies. www.acgme.org/outcome/comp/compMin.asp. Accessed Oct. 26, 2011.
- Sargent JR, Osborn LM, Roberts KB, DeWitt TG. Establishment of primary care continuity experiences in community pediatricians’ offices: nuts and bolts. Pediatrics. 1993;91(6):1185–1189.
- Roberts KB, Starr S, DeWitt TG. The University of Massachusetts Medical Center office-based continuity experience: are we preparing pediatrics residents for primary care practice?Pediatrics. 1997;100(4):E2. doi:10.1542/peds.100.4.e2 [CrossRef]
- Whitcomb ME. What community-based education can teach tomorrow’s doctors. Acad Med. 2005;80(4):315–316. doi:10.1097/00001888-200504000-00001 [CrossRef]
- Rushton FE Jr, American Academy of Pediatrics Committee on Community Health Services. The pediatrician’s role in community pediatrics. Pediatrics. 2005;115(4):1092–1094. doi:10.1542/peds.2004-2680 [CrossRef]
- Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356(8):858–866. doi:10.1056/NEJMsb061660 [CrossRef]
- Baron RJ. What’s keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362(17):1632–1636. doi:10.1056/NEJMon0910793 [CrossRef]
Stanley I. Fisch, MD, leads a group practice and is a clinical professor of pediatrics at the University of Texas School of Medicine at San Antonio. He has chaired the Resident Education and Training Special Interest Group of the American Academy of Pediatrics Section on Community Pediatrics and is the editor of the Starter Kit for Community Preceptors faculty development toolkit.5 Dr. Fisch received the AAP 2006 Job Lewis Smith Award for Leadership in Community Practice.
Medical education has not kept pace with the drastic changes in how community health care is now delivered. The load of infectious disease cases, once a bastion of pediatric practice, have been largely reduced because of vaccine development. In turn, office-based general pediatricians refocused their attention on the “new morbidity” — problems of learning, behavior, growth and development, and individual and family stress.
Inpatient pediatrics in both the nursery and ward has taken on a higher acuity of care, and hospitalists have progressively been replacing community pediatricians as the main caregivers in those settings. More recently, our successes in improving the outcomes of preterm infants, children with congenital defects, and childhood cancer have further changed the pediatric population in the community.
The Accreditation Council for Graduate Medical Education (ACGME) proposed its general competencies6 as a way to improve the fit between the training world of the resident and the practice world of the community clinician. By making residency training less prescriptive and more oriented to outcomes, it was hoped residency program directors would be free to innovate and create programs better preparing residents for their career choice. More explicit attempts to reorganize pediatric residency training are generating significant discussion7,8 but no clear direction for the future.
Another concern among medical educators is how well students and residents acquire — and how well medical education nurtures — a sense of professionalism. Students and residents hear the “formal” talk about professionalism but, in daily rounds, witness unchallenged instances of unprofessional behavior by peers and teachers. Educators face the added challenge of inspiring “civic professionalism”9 — commitment to the welfare of all children in the community, not only to those present as patients within an individual practice.
Placing students and residents in community settings allows learners to experience and appreciate the social, cultural, and economic contexts of care. Practices that embrace the principles of “community pediatrics”10 serve as exceptional models of care sensitive to context and professionalism.
Challenges of Community-based Rotations
Community-based learning and practice are about continuity; ie, caring for children and families over time. Continuity is the essence of community practice — in most cases not easily duplicated in residency programs. Pediatric residents, regardless of whether they choose general pediatrics or a subspeciality, must appreciate the challenges and complexity of continuity of care and the concept of the medical home in the community environment.11
Managing children, especially those with chronic conditions, requires teamwork. Teamwork can be taught in abstract but must be experienced where continuity and teamwork are practice norms.
Clinicians create, analyze, and take action based on large databases of information about individual patients and families. Sometimes, the databases are incomplete; some things are unknown or unknowable. Making clinically logical and reasonable inferences from available but incomplete datasets is an essential skill for all physicians. Seeing patients over time affords practitioners feedback and allows them to refine their approach to patient care.
Community-based learning and practice are also about managing ambiguity. Patients often present with complaints, symptoms, and signs, the meanings of which are not always clear. The challenge for the learner and experienced clinician alike is using clinical reasoning, empathy, and “cultural competence” to formulate a problem and explain it to a patient and family in a way all can understand and work together to solve.
Challenges of Community-based Precepting
Having learners in one’s practice requires careful thought, and comes with added roles, responsibilities, and expectations. There must be agreement in the practice about how to fit learners into the workflow with minimal disruption. Preceptors must understand the needs of trainees while managing their own patient care responsibilities. Since time management is among the many skills residents can learn in a community practice, successfully balancing program and trainee expectations is an opportunity to model good work habits.
Community-based learning is experiential. Preceptors can bolster the value of experiential learning by encouraging the learner to reflect, which in turn affords the teacher opportunities for meaningful feedback and guidance.
In this decade of competency-based education, it is not unreasonable to expect participating community practitioners to avail themselves of faculty development exercises to enhance their teaching. The American Academy of Pediatrics (AAP) has a resource to help pediatricians begin their teaching roles,5 but nurturing from academic training programs must be an ongoing commitment to communitybased faculty.
Lynda M. Young, MD, runs a group pediatric practice in Worcester, MA. She has precepted medical students and residents from the University of Massachusetts, where she is Clinical Professor of Pediatrics. In 2004, she received the Academic Pediatric Association-American Academy of Pediatrics Community Teaching Award.
For more than 20 years, our office has been a continuity clinic site for pediatric residents at the University of Massachusetts Medical School in Worcester, MA. UMass was one of the first two programs in the US to develop resident continuity experiences in community pediatrician offices with one-on-one precepting.7,8
Each community preceptor is committed to completing a faculty development program before teaching a resident in the office and to attending meetings and a yearly retreat during their tenure as a preceptor. Preceptors contribute to the content areas of the retreat in addition to the office curriculum for the residents. Residents are given a 4-week block rotation early in their first year to become familiar with their office setting and personnel; develop their patient panels; and visit key places in their practice community, such as schools, youth centers, and local police and fire departments. During their third-year block rotation, they are afforded the opportunity to see other offices, hospital-based settings, and employed physician practices.
Both preceptors and residents have reported enjoying this office experience. Of those residents who have chosen subspecialties as their career choice, they relate that their time spent in primary care offices was invaluable in understanding the broad range of services in practices and communities, and the importance of continuity and communication. For many practices in our program, this community model has given residents the opportunity to continue in the practice after training. There are distinct advantages to hiring your residents — you know them, you trained them, and they know you and your practice.
Division of Community Pediatrics
We also work closely with our academic health center (AHC), UMass Memorial Children’s Medical Center. In 2000, the department chair created a Division of Community Pediatrics, of which I am the director, with an annual stipend. My duties are to connect the department and community pediatricians. I communicate electronically with pediatricians, and we have up to three meetings a year where we meet new faculty, and hear updates from the chair and faculty members regarding new services or programs. I have a seat and vote at the table of division chief meetings, and I am able to communicate about problems. I recruit new preceptors and mentors for medical students and residents, review credentialing applications of all our division members, and support their requests for faculty appointments and promotions.
Since community offices represent rich laboratories for scholarly projects around patient care, collaboration between the academic center and community offices is encouraged. In recent years, my own office has participated in several projects initiated by various subspecialists. Also, we are a Pediatric Research in the Office Setting (PROS) site through the AAP.
A major challenge is how the department of pediatrics at the university recruits community pediatricians to teach in the office within the current environment of health care reform.12 Having a community physician-designated chief of community pediatrics can be very helpful in demonstrating the department’s commitment to training in primary care. Based on our experiences, we would suggest some tips for recruiting new preceptors:
- Ask faculty and residents which community physicians they value and with whom they have had the most contact;
- Target pediatricians who are active in their local, state, and national organizations;
- Issue a call for preceptors through emails, grand rounds, or departmental meetings.
Rewards of Precepting
While most programs do not pay community pediatricians for precepting, the rewards include working closely with pediatric trainees and exchanging ideas, using residents’ expertise in the latest technologies to enhance one’s practice, and receiving fringe benefits from the AHC, such as discounts at CME programs or free parking.
For our annual retreat, held offcampus, the department pays for all preceptor expenses except travel. Participants receive CME credits and time with subspecialists to whom they refer. Precepting in the office qualifies one for a clinical faculty appointment in the medical school and can lead to a promotion within this system based on contributions over the years. Acknowledging a practice’s participation in the program with a framed plaque/certificate alerts families to the commitment this office makes to the training of future pediatricians and to the esteem in which it is held by the AHC.
David Bromberg, MD, has practiced general pediatrics in Frederick, MD, for more than 30 years, and is a Clinical Associate Professor of Pediatrics at the University of Maryland. He is a recipient of the Maryland AAP Leadership Award, Pediatrician of the Year Award, and the APA-AAP Community Teaching Award.
In 1994, the department of pediatrics at the University of Maryland was faced with two challenges: increased demand for training in ambulatory pediatrics with a limited number of sites available; and pediatric residents experiencing fewer contacts with, and less teaching from, community practitioners. In essence, many residents who decided on a career in community-based office practice had no opportunity within the curriculum to experience how an office practice actually functions.
The chair of the department decided to develop an ambulatory pediatrics experience in community practices. Key components included: hiring a community practitioner to head the program; placing that person administratively as a division head within the department; and giving the program prominence by locating it in the chair’s office. These elements led to the success of the program.
Tenets of Program Development
The decision to develop a community-based continuity clinic program was modeled on the program at the University of Massachusetts.7 A joint community and university committee to establish the program subsequently was founded.
Each resident was given two continuity experiences each week — one university clinic-based, and one in a pediatric practitioner’s office. The continuity program began with a single clinic the first year, adding the second clinic for the PL-2 and PL-3 years. Community faculty suggested that the community setting offered an environment with a greater percentage of kept appointments and fewer socioeconomic issues to consider, and therefore would make it easier to teach the fundamentals of well-child health care. Thus, the PL-1s began in community practices, despite concerns about new residents experiencing their first ambulatory training off-site.
The fact that this program was created jointly by academic and community faculty was instrumental in getting “buy-in” both from AHC faculty and from community pediatricians, who recognized that the demands being placed on them would be developed by people who understood the pace and financial constraints of office practice. By hiring a community pediatrician to head the program and using community faculty for program development, the chair clearly demonstrated strong departmental support for the activity, as well as respect for the contribution of community faculty.
There were several departmental benefits from having a community practitioner on campus: a community perspective being offered at resident conferences; community-academic faculty interchange on curriculum development; and access to community sites for clinical research projects. One such project identified and addressed some of the underpinnings of child abuse and was expanded to include a network of community faculty. The trust of the community pediatricians in the Community Practice Program proved invaluable in helping to successfully establish this network.
Residents benefited most from having a well-developed Community Practice Program. Community rotations consistently received excellent reviews from the residents, and community faculty were highly rated as teachers. Having a community-based practitioner on campus allowed conferences and discussions about community-based care delivery systems. The residents had a ready resource for career counseling as they considered a career in communitybased practice. The residents shared information with each other about their community sites, resulting in many residents finding practice opportunities from within the network. As new educational challenges were presented to the Division of Education, it was easier to consider community sites as a venue for addressing these challenges.
Part of the Community Practice Program was faculty development seminars that were jointly attended by community and academic faculty. As these seminars matured, the group took on challenges, such as teaching behavioral and developmental issues in community continuity sites.
Budgetary constrains ultimately presented a problem for the Community Practice Program. With changing chairs and increasing demands for limited resources, the program became a target for budget cuts. There is no longer a community-based pediatrician on-site or as director, but the program continues with most of the original community faculty still participating.
Colleen A. Kraft, MD, is a primary care pediatrician, Carilion Pediatric Medicine; Medical Director, Medical Home Plus; and Associate Professor of Pediatrics, Virginia Tech Carilion School of Medicine. She is a co-author of the book Managing Chronic Health Needs in School and Child Care (AAP, 2009). She was the 2005–2007 Walter E. Bundy Jr., MD, Professor of Community Pediatrics, and serves on the Executive Committee of the AAP Council on Community Pediatrics and the Medical Home Project Advisory Committee.
As a medical student and pediatric resident at the Medical College of Virginia in the mid- to late 1980s, it was always a treat to be on service with Walter E. Bundy Jr., MD, Clinical Professor of Pediatrics. Dr. Bundy was a true community pediatrician; he had trained near the coal mines of West Virginia. He knew all about tuberculosis, miner’s lung, polio, and pertussis. He could accurately diagnose congenital heart lesions using only a stethoscope. He understood the social determinants of child health long before anyone used that specific terminology.
‘Listen and Learn’
Dr. Bundy saw kids in his office, in their homes, in the nursery, and as an attending at the AHC. He lived in the trenches, yet was revered by the pediatric faculty at the Medical College of Virginia (MCV). Dr. Bundy taught how pediatric educators could listen and learn from their communities. He could mix humor with pathophysiology and life lessons, instilling in his students a reverence for children and an appreciation for what they needed from their doctors.
Managed Care as ‘Gatekeeper’
The early 1990s brought changes to the leadership of both the department of pediatrics and MCV. A certain amount of distance developed between the medical center and the community. As fewer specialists were trained, community pediatricians found it more difficult to access specialty care for their patients. As managed care emerged and the “gatekeeper” function of primary care became all too apparent, the gap between “town and gown” widened.
Even the Richmond Pediatric Society, the one opportunity for both academic and community pediatricians to meet for CME and socialize, became less relevant because many young pediatricians preferred time with their family over attending meetings. The institutional leadership changed the school’s name to the Virginia Commonwealth University (VCU) School of Medicine. Several different plans for a full-service children’s hospital in Richmond did not materialize during this time. The residency program, with new ACGME guidelines and duty hours, removed pediatric residents from the hospital where many of the community pediatricians admitted patients. New community-based hospitalists and facilities gained referral business from the practicing pediatricians because of improved communication and proximity to where their patients lived.
The Richmond community — and VCU — needed a Dr. Bundy.
The Walter E. Bundy Jr., MD, Professorship in Community Pediatrics was founded to rebuild the relationship between town and gown, and support a community pediatrician in a teaching role for students and residents in the VCU pediatrics department. The professorship was the vision of retired community pediatrician Fred Rahal, MD, who made a substantial contribution to the endowment. Barry Kirkpatrick, MD, vice chair of the department, worked with Dr. Rahal to solicit funds and develop a process by which the Bundy Professor would be chosen. The Bundy Professor would serve as that “bridge” between town and gown, and would become the nominal “Chair” of Community Pediatrics at VCU. The Bundy Professor would earn a salary for 2 years, have a formal teaching role for students and residents, serve to strengthen ties between VCU and the community, and champion a pediatric cause during his/her tenure.
When I was the Walter E. Bundy Jr., MD, Professor of Community Pediatrics (from 2005 to 2007), the Richmond community had several Latina health workers who could serve as cultural mentors. Parents of children with special health care needs became some of my most savvy “resource coordinators” for other parents. The “medical village,” including schools, child care centers, and Head Start classes, together formed a sort of laboratory for translational research in the implementation of evidence-based programs to promote social-emotional health, prevent smoking, and decrease incidences of bullying.
Today’s pediatric residents understand, as Dr. Bundy understood, that life course health trajectories are set in the context of social determinants. Community pediatrics is emerging as its own amalgam of public health, advocacy, and translational research. I have since moved to Roanoke, VA, to address challenges children and families face in Appalachia. Dr. Bundy’s principles are becoming the foundation of a new Pediatric Residency at the Virginia Tech Carilion School of Medicine and Carilion Clinic.
These four pediatricians offer perspectives on how bridging the gap between academia and the community enriches practice and benefits the next generation of physicians. Flexner took us from the community to the university, from one extreme to the other. It is high time to recognize, embrace, use, and celebrate the power of synergy between town and gown in pediatric education.
— Kenneth B. Roberts