Analysis of a straight pediatric internship

1 10

July, 1971 T h e ]ournal of P E D I A T R I C S

Analysis of a straight pediatric internship Detailed records o[ all patient contacts in one individual's straight pediatric internship were kept. Analysis o[ the data showed a greater exposure to acute disease and commonplace problems than was expected. Examination o[ the intern's degree o[ involvement (responsibility) and independent study showed little difference between inpatients and outpatients or between new and "inherited" patients.

Peter D. Wallace, M.D., and David L. Silber, M.D. '~ IOWA CITY, IOWA

P ~ D r A T a I c postgraduate training receives considerable criticism, most of which focuses on the discrepancies between experience provided in traditional programs and the skills required to deliver primary health care. 1-5 Frequently these attacks are based on attitudinal surveys of practitioners who have been asked to evaluate their own training retrospectively. Data from such efforts describe programs as they once were; such descriptions may not apply to the present. A recent study by Levine and associates 6 illustrated the value of detailed, prospective analysis of the content of ongoing programs and prompted us to seek independent data for comparison. In addition, we were interested in certain educational aspects of internship which, to our knowledge, have not been studied previously.

METHODS In order to examine these aspects of a straight pediatric internship, we studied one intern's (P. D. W.) experience from June From the Department of Pediatrics, University of Iowa Hospitals. ~Reprlnt address: Department o[ Pediatrics, University o] Iowa Hospitals, Iowa City, Iowa.

Vol. 79, No. 1, pp. 110-113

23, 1969, through June 22, 1970. This entire program took place within the University of Iowa Hospitals and Clinics which comprise a large referral center with only full-time faculty. Community-oriented services, such as emergency room and %valk-in clinics," exist on a smaller scale than in most centers located in large metropolitan areas.

See Editor's column, p. 179. The internship studied included 9 months on inpatient services (which included one month in the newborn nursery), one month on the outpatient service, one month as "admissions officer," and one month of elective time which was spent in pediatric radiology. The intern had night duty assignments throughout the entire year. Data were recorded on 3 x 5 index cards and later transferred to McBee cards for compilation. Diagnoses were recorded in code using a modification of the system introduced by Lenoski and associates. ~ The same data were recorded for each patient contact. A patient contact was defined as every encounter with a patient in which the in-

Volume 79 Number 1

tern's minimum activity included an evaluation of the patient's medical history and physical findings. Brief encounters which involved only interim care, or procedures such as writing sedative orders or performing venipuncture, were not included. Coded data recorded were as follows: (a) patient identification and status (age, inpatient or outpatient, "new" patient or "inherited," etc.), (b) primary and secondary diagnoses, (c) nature of the disease state (acute or chronic), (d) degree of continuity (previous contacts with the same patient such as previous hospitalization or outpatient visit), (e) degree of involvement in management (whether intern's decisions were of no, some, or vital significance), and (f) educational resources utilized (including all forms of consultation sought within 8 hours of the contact, i.e., none, textbook, journal, fellow house officer, teaching faculty).

Straight pediatric internship

Table I. Characteristics of patient contacts

Characteristics Inpatient contacts Outpatient contacts

I No. of

patients 1,190 451 1,641

Acute problems Chronic Problems

1,113 528 1,641

New patient Inherited patient Seen on call Emergency room Ambulatory clinic Ambulatory clinic with student Presented at conferences Discussed on rounds

468 112 375 177 84 109 58 258 1,641

Age groups 0-7 days 8 days-1 yr. I yr.-5 yr. 5 yr.-15 yr.

458 394 362 427

1,641

RESULTS A total of 1,641 patient contacts with 1,265 separate patients was recorded during the internship year; 1,216 of the contacts were with patients for whom primary responsibility was assumed. Also included were contacts with 58 patients who were presented and discussed at length at various departmental conferences, 258 patients who were discussed in detail during teaching ward rounds, and 109 patients who were seen by the intern in conjunction with a medical student in an ambulatory clinic. Twenty-seven per cent of the patient contacts occurred in an ambulatory setting. In contrast to Levine and associates '6 findings, assigned time and patient contacts were proportional, i.e., three quarters of the year were spent on inpatient assignments during which 73 per cent of the patient contacts occurred. These data are summarized in Table I. In about three quarters (1,113 of 1,641) of the contacts, the primary problem was classified as acute. For each patient contact, the primary medical problem (diagnosis) was recorded, as well as any significant secondary or tertiary problems. For example, 3 entries were made for a patient with con-

111

Contacts Initial or only Second Third Four or more times

1,265 216 65 95 1,641

genital heart disease, pneumonia, and congestive heart failure. The 2,265 diagnoses recorded are shown in Table II. Twenty-eight per cent of all patient contacts were with patients in the first week of life; roughly the same portion were patients in the 5 to 15 year age group. Patients aged 8 days to 1 year and 1 year to 5 years each accounted for slightly less than one fourth of the patient contacts (Table I). Almost one third of the patients were seen on at least one additional occasion, i.e., another hospitalization or follow-up outpatient visit. In this group was a number of patients who were followed on a "private patient" basis. Table III also shows data which reflect on the educational value of each patient contact. In 244 of the 1,641 patient contacts (15 per cent), the intern felt that his role was minimal and that he made no decisions which

112

Wallace and Silber

The Journal o[ Pediatrics July 1971

T a b l e I I . Diagnoses a n d diseases e n c o u n t e r e d in 1,641 p a t i e n t contacts

D!agnoses and diseases I. Allergic Asthma Drug reactions Urticaria Contact dermatitis Miscellaneous II. Cardiovascular Congenital heart disease Functional murmur Congestive heart failure Paroxysmal atrial tachycardia Cardiac arrest Rheumatic fever Miscellaneous III. Hematologic Hemophilia Leukemia Erythroblastosis fetalis Idiopathic thrombocytopenic purpura Iron deficiency anemia Hereditary spherocytosis Hemolytic anemia Histocytosis X Consumption eoagulopathy Miscellaneous IV. Infectious Respiratory Otitis media Pneumonia Gastroenteritis Tonsillitis Meningitis Urinary tract infection Abscess Conjunctivitis Septicemia Appendicitis Encephalitis Rubella Miscellaneous

I No. of

patients 14 7 7 9 4 102 17 30 5 23 7 53 55 29 28 8 6 5 4 4 5 50 136 106 60 58 40 26 13 13 12 9 9 8 6 75

V. Metabolic and endocrine Fluid and electrolyte disorder Failure to thrive Dibetes mellitus Nephrosis Cystic fibrosis Miscellaneous

80 18 13 8 79

VI. Muscular and orthopedic Congenitally dislocated hip Muscular dystrophy Club feet Rheumatoid arthritis Miscellaneous

15 14 8 8 32

71

Table II. Cont'd

No. of

Diagnoses and diseases VII. Neonatal Prematurlty Respiratory distress syndrome Hyperbillrubinemia Miscellaneous VIII. Neurologic Convulsive disorder Tumor Hydrocephalus Headache Mental retardation Cerebral palsy Behavior disorder Miscellaneous IX. Surgical Hirschsprung's disease Pyloric stenosis Laceration Cleft palate and lip Bowel obstruction Imperforate anus Tracheoesophageal fistula Inguinal hernia Miscellaneous X. Well child XI. Miscellaneous Fever of unknown origin Drug ingestion

h a d a significant effect on the course. H e felt t h a t his decisions some significance in 1,229 contacts cent) a n d of vital significance in 11

patients 86 54 49 5 63 21 11 8 8 7 6 83 12 11 11 12 8 8 8 7 95 276 53 24

patient's were of (74 p e r p e r cent

(Table In). I n roughly half of the p a t i e n t contacts, the intern d i d not seek consultation of any kind on m a n a g e m e n t decisions within the first 8 hours of contact with the p a t i e n t ( T a b l e I V ) . I t should be noted, however, t h a t he only recorded consultations which he initiated. A m o n g the patients for w h o m no consultation was sought, there were m a n y supervised p a t i e n t contacts in which unsolicited information was supplied a n d decisions were m a d e b y senior house officers or faculty. I n the r e m a i n i n g 790 contacts in which the intern sought consultation, verbal consultation with senior members of the patient-care team was far more frequent t h a n the use of p r i n t e d references. W h e n inde-

Volume 79 Number 1

Straight pediatric internship

Table I I I . Significance of intern's decisions Outpatient

NumNone Some Vital

bet 11 425 15

Inpatient

N~e~ % 2 95 3

233 804 153

% 19 67 14

Totals 244 1,229 168 1,641

pendent reading did occur, textbooks were used 8 times more often than periodicals. The intern referred to textbooks in 28 per cent of inherited patients versus 15 per cent of new patient contacts and to journals in 7 per cent of inherited versus 3 per cent of new patient contacts. Consultation with faculty occurred in 52 per cent of inherited versus 31 per cent of new patient contacts, but consultation with fellow house officers occurred in only 3 per cent of inherited versus 24 per cent of new patient contacts. In 65 per cent of the outpatient contacts, the intern initiated treatment with no outside aid; this occurred in 39 per cent of inpatient contacts. Additional related reading occurring beyond 8 hours of the initial contact was not recorded. DISCUSSION

Comparison of the content of internship to the content of practice has limited meaning for at least 2 reasons. First, the internship comprises only one third (or less) of the pediatric trainee's total postgraduate training, and some important experiences which are absent in internship will be included in subsequent residency programs. Second, training programs must prepare the individual for competence with unusual as well as usual problems. Three quarters of this intern's patient contacts were with hospitalized children, which is in contrast to the predominance of ambulatory patients seen by the practitioner.8, 9 However, the medical problems encountered with these hospitalized patients were representative of commonplace pediatric diseases; relatively few of the contacts involved exotic conditions unlikely to be seen again. These findings fail to support

113

Table IV. Resources used within first 8 hours of patient contact Outpatient Inpatient NumNumber % ber % None 306 65 545 39 Text 24 5 191 13 Journal 1 <1 31 2 House officer 69 14 255 18 Faculty 77 16 296 28

Totals 851 215 32 324 473

the charge frequently made by our own graduates that our service, as well as most other university programs, deals almost exclusively with rare chronic disease rather than with the more common acute problems. The degree of teaching effort associated with the ambulatory patient often is less than that with the hospitalized patient. Though we did not measure teaching per se, we did examine the intern's use of consultation and found that educational resources were utilized only slightly more on inpatient services. This may be a reflection of greater availability of resources or of more complicated problems on inpatient services. House officers generally regard their degree of responsibility in patient management as an important measure of the educational value of a training program. In this respect, our data indicate that the intern in this study felt that his involvement had substantial significance. Another common attitude among trainees is that the physician becomes less involved with and learns less from the "inherited patient" than with the "new" patient whose initial evaluation he conducted personally. We compared the intern's experience with these 2 groups and found no significant difference. T h e frequency with which various educational resources were employed was greater with inherited than with new patients. No resources were used in 59 per cent of new patient contacts as opposed to 21 per cent of inherited patient contacts. New patient contacts included a large number of patients seen in the newborn nursery and various

1 14

Wallace and Silber

ambulatory clinics and were essentially well children about w h o m consultation was rarely needed. We examined the data for variations in the intern's responsibility and use of resources throughout the internship year. I n general, the differences found were a reflection of the service to which he was assigned and the type of patients with w h o m he was involved rather than his previous experience. His internship year began and ended with assignment to the same service (sick-infant area), and in these 2 separate periods the data on level of responsibility were essentially identical. We did find a trend toward decreased utilization of resources; in his first month, no resources were employed in 20 per cent of patient contacts whereas in the final month, on the same service, no resources were used in 51 per cent. This study provided us with previously unavailable documentation of the content of our internship program and information on some of the learning activities therein. We feel that it would be prudent for all programs to be analyzed in a similar way. Having accumulated these data, comparison with

The Journal of Pediatrws July 1971

the stated objectives of the program can be made and needed alterations can be identified. REFERENCES

1. Haggerty, R. J.: Family medicine: A teaching program for medical students and pediatric house officers, J. Med. Educ. 37: 53I, 1962. 2. Coddington, R. D.: The baby doctor's behavior, Pediatrics 35" 147, 1965. 3. Hessel, S. J., and Haggerty, R. J.: General pediatrics: A study of practice in the mid1960's, J. PEDAT. 73: 271, 1968. 4. Richmond, J. B.: Some observations on the sociology of pediatric education and practice, Pediatrics 23:1175, 1959. 5. Deisher, R. W., Derby, A. J., and Sturman, M. J.: Changing trends in pediatric practice, Pediatrics 25: 711, 1960. 6. Levine, M. D., Robertson, L. S., and Alpert, J. J.: A descriptive study of a pediatric internship, Pediatrics 44: 986, 1969. 7. Lenoski, E. F., Itanes, B., and Wingert, W. A.: Computer processing of pediatric emergency room data, J. A. M. A. 204: 139, May, 1968. 8. Aldrich, R. A.: Careers in pediatrics, in Spitz, R. H., editor: Report of the Thirty-sixth Ross Conference on Pediatric Research, Columbus, I960, Ross Laboratories. 9. Breese, B. B., Disney, F. A., and Talpey, W.: The nature of a small pediatric group practice, Pediatrics 38: 264, 1966.