Pediatric Residency Training – PediaCast 220

Dr John Mahan and Dr Tricia Lucin visit the PediaCast Studio today to discuss pediatric residency training. We’ll de-mystify the black box that produces American doctors and give you an insider’s look at living the life of a resident. For those interested in pursuing a career in pediatrics, we’ll provide hints on what makes a strong program and describe the many career opportunities available to those who finish a pediatric residency.

Topic

  • Pediatric Residency Training

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Transcription

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.

It is Episode 220, 2-2-0, for August 1st, 2012. We're calling this one Pediatric Residency Training. I'd like to welcome everyone to the show. We have a great one lined up for you today, and we're kind of gearing this one to two different crowds, but I think everyone will find the information pretty interesting.

01:01

First up, for the parents, medical training is like a black box for many of you. A kid graduates from high school, they kind of go into the box, and they come out a practicing physician. And you may have heard some of the pieces, parts that are inside that box, things like undergraduate school, medical school, MCATs, medical boards, internship, residency, fellowship, all these terms that are out there that you've probably heard of but don't necessarily have a grasp of what they really mean and how the pieces all fit together. So if that describes you, you are in luck, because we are going to demystify the process today.

But we're also going to gear the show for those of you who wish to pursue a career in pediatrics. I know we have a lot of high school students, undergraduate students, medical students in the audience who are interested in becoming a pediatrician or a pediatric sub-specialist, and we are going to satisfy your appetite as well by going a little bit deeper into the inner workings of a pediatric training residency program: what's it like on the inside, what it's like actually being a pediatric resident, if you want to become a pediatric resident, what you should look for in a program, what skill sets will you have when all is said and done, and what job opportunities lie on the other side.

02:20

To help me answer these questions, we have a couple of great studio guests joining me today. Dr. John Mahan is the Director of the Pediatric Residency Training Program at Nationwide Children's and the Ohio State University, and Dr. Tricia Lucin is a second-year pediatric resident who is knee-deep in her pediatric training here in Central Ohio.

But before we get to them, I want to remind you, if there is a topic that you'd like us to discuss on the program or you have a question for us, it's easy to get a hold of me. Just head over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S.

I also want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. So if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

03:16

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

All right, so let's turn our attention to our studio guests today.

Dr. John Mahan is the Program Director for the Nationwide Children's Hospital Ohio State University Pediatric Residency Training Program. He is also a professor of pediatrics at the Ohio State University College of Medicine and a pediatric nephrologist at Nationwide Children's. 'Nephrologist', for those of you who may be scratching your head, is the medical term for a kidney specialist.

In addition to training new pediatricians, Dr. Mahan is also involved with training new kidney specialists in his role as Program Director for the Pediatric Nephrology Program at Nationwide Children's. Rounding out his duties, Dr. Mahan serves as Chairman of the Post-Doctoral Education Committee for the Ohio State University Department of Pediatrics and serves on the Medical Advisory Board of the National Kidney Foundation of Ohio.

04:09

It is with a warm greeting that we welcome Dr. Mahan to the PediaCast Studio. Thanks for stopping by.

John Mahan: Thank you, Dr. Mike.

Mike Patrick: I really appreciate it.

Joining Dr. Mahan, we also have Dr. Tricia Lucin. She is a second-year pediatric resident here at Nationwide Children's Hospital. Her hometown is Coshocton, Ohio. She did her undergrad work at the Ohio State University and then attended medical school at Wake Forest University. She's back in Central Ohio to complete her pediatric training.

Welcome to you as well, Dr. Lucin.

Tricia Lucin: Thanks for having me.

Mike Patrick: I really appreciate both of you stopping by.

John Mahan: And Dr. Mike, I want to remind you, I do get credit for recruiting Tricia back to Central Ohio.

[Laughter]

Mike Patrick: You were personally responsible for that.

John Mahan: Personally.

Mike Patrick: So we're going to end up having two… Actually, you recruited me to Nationwide Children's Hospital as well.

John Mahan: I'm not sure we can go back that far.

Mike Patrick: [Laughter] It's been a long time.

05:02

So we're really looking at this from two perspectives today, one from the program director of, I may be a bit biased, but I'll say one of the best pediatric training programs in the country, and a view from the trenches with an actual real-life pediatric resident.

Dr. Mahan, let's start with you. Just briefly, what is a pediatric resident? What is their role and how do they fit into the rest of the hospital?

John Mahan: Yes. A pediatric resident is an individual that's completed medical school, so this is someone who has completed four years of medical school and has passed the appropriate U.S. medical licensing examinations.

To become a pediatric resident, that medical student, during the third and fourth years of medical studentship, needs to apply to a pediatric residency and acquire a position. When that resident comes on board as a pediatric resident, in our state they're given a temporary medical license because they are a graduate of medical school and have passed these licensing exams, and then during their residency, their task is to learn the discipline of pediatrics.

06:11

So what they're about is learning the knowledge that a pediatrician needs to learn to develop the skills at a high level that a pediatrician needs to be able to master, and also develop the right kind of attitudes that allow a pediatrician deliver quality care.

Mike Patrick: Sure.

John Mahan: At the end of three years of training, the graduates of an accredited program such as we have are now eligible to sit for the pediatric boards to become a board-certified pediatrician. So that's another hurdle that the graduates of our program get to take on about five months after they graduate from the residency program.

Mike Patrick: Sure. So if we sum up the steps and order, a graduating high school student would go to undergrad and be a pre-med student for four years, and then they would go to medical school for another four years. At that point, they are a physician and they're licensed as long as they have passed at that point, I think, two sets of board tests.

07:11

John Mahan: Correct.

Mike Patrick: Then they are a physician, they have a medical license, but, just on a little bit of everything, they haven't necessarily done their pediatric concentration. So then the first year of residency, we're going to call that an intern?

John Mahan: Yes.

Mike Patrick: That's another one of those terms that gets floated out there. So then they're a resident in pediatrics for three years. During that time, they're going to take a third medical board to complete their licensure. They have a temporary license until they complete that one. And then we'll get into fellowships a little bit later.

So that's kind of that sequence that students have to take. Right?

John Mahan: Correct.

And we certainly have students that take non-traditional pathways. There are individuals that are in a career and decide to go back and go to medical school. There certainly are individuals that may take some time off between medical school and residency. So it's not linear for everyone, but what you just described is the typical pathway. And it's quite an arduous pathway.

08:08

Mike Patrick: Yeah. And there are some programs that kind of combine a little bit of the undergrad and the medical school so that it's like a six-year program and you do… Not very many of those out there, but one in Ohio.

John Mahan: Correct.

Mike Patrick: So Dr. Lucin, you just went through all that.

Tricia Lucin: That's right. [Laughter]

Mike Patrick: This sounds very familiar.

Tricia Lucin: That's right. I just actually finished the third step test that you mentioned, the third licensing exam. So I'm official. [Laughter]

Mike Patrick: As I recall, that one was the easiest, wasn't it?

Tricia Lucin: It was, but none of them are easy.

Mike Patrick: No, right, right, right. Relatively. [Laughter] Relatively easy.

Because we get email and people use the contact form, I know there are some high school students who listen to this program, who want to be pediatricians when they are all finished with their training, so as you look back to where you've been, what kind of high school experience and then what kind of college experience would you say would be helpful for someone who is interested in pursuing a career in pediatrics?

09:06

Tricia Lucin: Sure. Well, I think in high school the biggest thing is to get your sciences in as best as you can. I know that I took a few history classes during the summer so I had more time for advanced science classes in high school. Not everybody offers that, but if they do, that's a great thing to do.

And then I'm one of the non-traditional people that Dr. Mahan spoke of. My undergraduate degree is in Education, actually, and then I took some time off before medical school. But what I would say as far as undergrad goes is to find something that you're passionate about, something that you can enjoy spending your time with that will get you to that pre-medical pathway but that you can enjoy your time along the way because that's a long four years if you're not enjoying it.

Mike Patrick: Right. Absolutely. So you're a good example of 'it's not too late'. If someone, they're in undergrad and doing something that's non-science necessarily, they could still go back and get their pre-med requirements.

Tricia Lucin: Absolutely. And after I graduated and decided that I wanted to go to medical school, I did have to go back for a few more pre-requisite classes, but it didn't take much, and once you have that desire and that drive to do it, it doesn't seem like much.

10:10

Mike Patrick: Right. Now, were you going to be a Science teacher? Did you have quite a bit of science…

Tricia Lucin: Yes. Math and Science Education, correct.

Mike Patrick: Yeah. So that helped you out a little bit?

Tricia Lucin: Yes. [Laughter]

Mike Patrick: [Laughter] And then what about during the… Obviously course work is going to be important with the strong science background, the Chemistry, Organic Chemistry, Physics and Calculus, that kind of thing; are there any things that people ought to do during those pre-medical school years to find out if they really like the medical field?

Tricia Lucin: Sure. I think a great thing to do is volunteer at a hospital. We've got lots of hospitals in the area that take volunteers that are a little bit younger. In that way, you can see what happens in a hospital. I know a lot of practitioners in the area will take students to shadow for a day and see what's it like. I think just getting some exposure is great.

And then as far as the extra-curricular activities go as a whole, again, I think it's finding your passion and finding something to talk about that really drives you, and those are the best sort of activities that you can do.

11:09

Mike Patrick: Great. Now what about, once you're in medical school, if you are interested in going into pediatrics, are there other electives in medical school still these days or are you pretty much scheduled the whole time?

Tricia Lucin: During medical school, your first two years are scheduled as class work, and then Years 3 and 4 you do a lot of rotations in the hospital. Medical schools require that you do a pediatric rotation, but after you get past your required rotations, you can certainly do electives that give you further exposure. Especially if there's a specialty that you are considering, you can do a rotation there.

Mike Patrick: Yeah, which is probably a good idea to make sure you… [Laughter]

Tricia Lucin: Absolutely.

Mike Patrick: …do you really like this?

Tricia Lucin: And the more exposure you can get, the more kids you can see, and the more people you meet.

Mike Patrick: Right. So as we step through this process, and now you're at the point where you just started the second year of your residency, tell us what kind of educational experiences are part of…

12:04

I think when families see a resident in the hospital, it's usually, there are kids in the hospital, the residents come in, take a look at them, then the team rounds, or if you're in the emergency department, a resident comes in and then an attending comes in. So I think parents who have been to a teaching hospital probably have that pretty good idea of what the clinical life is like or what you do. But you still have an educational component to this as well.

Tricia Lucin: That's correct.

Mike Patrick: Tell us what that looks like.

Tricia Lucin: Sure. Here at Children's, we actually have lots of noontime lectures. During our lunch, we get to sit and listen to whether it be a clinical experience that someone's had or an actual lecture from the hospital. And then we have three board review lectures that we have every Tuesday. And then additionally we always have grand rounds on Thursday, which is where an expert comes and tells us their experiences in the field.

We have lots of board review materials that we use at Children's to get ready for the peds boards. Those are all ongoing and most of them are available online if we can't make them in person, which is great. Especially at 3am when you're working overnight and you might have a bit of downtime, you can review those lectures and make sure you're not missing out on anything.

13:14

Mike Patrick: Great. And then, what about the clinical aspect of it? What does that look like? We talked a little bit that you see patients and you round in the hospitals, you see them in the emergency department and the clinics. That kind of sums it up?

Tricia Lucin: Yeah, that kind of sums it up, I think. We see a lot as residents, we get thrown around from specialty to specialty in the hospital and out of the hospital, so we get to see a little bit of everything to round out our careers, which is really great. But the clinical aspect is my favorite part. That's where you get to see the patients, and I think you learn best from the patients. They teach you something everyday.

Mike Patrick: Yeah. When you are in medical school, you rotate through; you do OB/GYN, you do surgery, you do internal medicine, pediatrics, so you rotate through all those things.

Tricia Lucin: Sure.

14:00

Mike Patrick: When you're a pediatric resident, do you have exposure, then, to the sub-specialty fields?

Tricia Lucin: Absolutely. You rotate through pulmonology, which is the lungs, and cardiology, which is the heart, and every specialty essentially that there is, and we're lucky here at Children's that we have all those specialties and we have fellows and attendings who are experts in those fields, so you get to see pretty much any specialty you like. You can see it and you can rotate through it and see those patients.

Mike Patrick: Yeah. We'll have… Go ahead.

John Mahan: And what Tricia and our residents go through is very much experiential learning. It's much more like an apprenticeship in the sense that you're going to learn by doing, you're going to learn by observing, you're going to learn by being in the middle of it. So our residents are really at the front line. They're seeing the patients many times first, but they're also operating in a very supervised environment with senior residents and faculty that are supervising their work.

And if I had to say the sort of distribution between formal didactic education and experiential learning, Patricia will just say the percentages…

15:02

Tricia Lucin: Ninety-five percent experiential. [Laughter]

John Mahan: That's what residency is about. Medical school is much more of the formal didactic.

Mike Patrick: Yeah.

I'm going to step aside from being the host for just a moment, and from someone who went through the residency program here, I practiced in, private practice, pediatrics for 10 years and I have to say, I was never surprised by something that I didn't know really what it was. I mean, the exposure here is just incredible. There's just so many patients that come through, and with a wide variety of things you really do see it all.

John Mahan: Yeah.

Tricia Lucin: I think that's one of the biggest reasons I came here is I knew I was going to be busy and I knew I was going to be tired, but I also knew I was going to see everything and that I would have the best exposure I could.

Mike Patrick: Yeah, absolutely. You really do here. And I've come across, I mean, you don't want to speak badly about people who are trained elsewhere, but when you do come across folks who are trained at other places, it's like, 'Oh, yeah, I've heard of that but I've never actually seen that before.' I'm like, 'No, I've seen it.' [Laughter]

16:03

John Mahan: And there is something to be said for training at one of the five largest children's hospitals in North America.

Mike Patrick: Yeah.

John Mahan: We have the luxury and privilege of taking care of a lot of patients. A lot of families bring their children to us.

And an important part of our mission is to train that next of generation of physicians, and from the families' perspective, having those residents and ultimately fellows involved in their care is really an important part for the residents and fellows. But I would also make the point that it's really an important part of delivering best care because they really allow us to extend what we can do for the kids.

Mike Patrick: Yeah. Absolutely.

Now, with all that work and with all that exposure, step us through, Dr. Lucin, a typical day. What time do you get up? What does a typical day in the life of a pediatric resident look like?

Tricia Lucin: Sure. I think a typical day is probably in the hospital. We have more in-hospital months than we do out-, so I would get up around 5:30, be to the hospital by 7, which is when we get checkout from the night team, which means we are told about all the patients overnight what happened, if there's anybody new, that sort of thing.

17:13

Rounds start around 9, so in the meantime, you go see your patients on your own, find out what happened overnight, talk to the families and be ready to present on rounds. Rounds entail the whole team, the attendings, the residents, medical students, the patients, and we try to make sure that our patients and their families are involved on rounds. We go discuss what's happening, what do we think we need to do, when can they go home, all of those important questions. Usually that lasts until about 11 or 12.

And then when we go to the noon lecture that we talked about where we'll either discuss an interesting case or have a lecturer come and speak to us. And then the afternoon is for getting work done. Usually we have some admissions or discharges that we can send home and lots of paperwork that goes along with those things. That goes until about 5:30, and at 5:30 we check out to the night team.

18:00

So all in all we're there usually from about 7 until 6 or 6:30 by the time checkout's done, and then you go try to get some rest and eat something.

Mike Patrick: Yeah. Are you married?

Tricia Lucin: I am.

Mike Patrick: And do you have kids?

Tricia Lucin: No kids.

Mike Patrick: No kids. How does that kind of schedule…and I'm sure there are folks in your class who do have kids?

Tricia Lucin: Sure. Yes. [Laughter]

Mike Patrick: So how does that kind of schedule mesh with family life?

Tricia Lucin: You know, it's hard, but it's doable, and I think that another big thing about Children's why I wanted to come here is that the people are fantastic. You have lots of great friends in your class and amongst classes and everybody is really supportive.

And I think it's important that your family, whether you have a significant other or children or parents or whoever, know what they're getting into that it's going to be hard. My husband's really supportive and I'm really thankful for that. But it can be hard. You have to make time for the important things.

Mike Patrick: Yup, absolutely. Even though you may be less quantity, just make sure the quality is there. [Laughter]

Tricia Lucin: Exactly.

Mike Patrick: Now, Dr. Mahan, folks have heard, they watch medical shows and just how many hours and how many patients, and you see the doctors and they're dog-tired and have trouble making decisions and that sort of thing. But there have been some strives in recent years to place a limit on the amount of work that residents do. Can you speak to that?

19:24

John Mahan: Certainly, Mike. The Accreditation Council, what we call ACGME, is the body that oversees resident fellowship training in the United States, and they basically set the rules. The big development that was rolled out in 2003 was the concept that residents and fellows should work no more than 80 hours a week. And for many families, they hear that and they go, 'They work more than that?'

[Laughter]

Mike Patrick: I remember weeks that I worked 100 hours. [Laughter]

John Mahan: 'What is going on in these hospitals?' Traditionally, since this is experiential learning, the thought was you need to experience it all and the idea was to be there for long periods of time, you could see patients evolve and take responsibility, and this was a good learning model.

20:10

However, the concerns that arose, particularly as we go through the 1980s and the 1990s, was, at some point, is fatigue potentially impacting in a negative way on the cure of the patients and also on the mental and physical health of the trainees? And the question was really raised, do you need to work 120 hours a week to learn?

The Accreditation Council did a very detailed analysis, a lot of study, a lot of expert testimony, and came up with this 80-hour work duty hour restriction that was put into place in 2003. Now, that did allow residents to spend up the 30 hours at one time. There were certain rules about how many days off. For example, a resident had to have at least four days off a month. Before that, literally you could have no days off, and that would be OK by the rules.

21:02

So these were the rules in 2003, very different, and really made all of us in residency training start intentionally thinking about what's the best next. Just running up more hours is not always necessarily the best. How do hours spent learning begin to impact on patient care and the outcomes with our trainees?

Since then, in 2011, the Accreditation Council did a further refinement, and again, based on some evidence but also a lot of expert opinion, decided to further limit the exposure of the trainees with the idea that this would improve patient care and the health of the trainees.

For example, Dr. Lucin as an intern was not allowed to spend more than 16 straight hours in the hospital, and again, most families will say, 'Sixteen? That's a lot of hours at a difficult job, and a lot of stress.' But before that, we could have individuals spend up to 30 hours at one time. So we're sort of the third generation now of how work duty hours are being enforced.

22:06

Mike Patrick: Those of us, you included, who trained before these kinds of limits were placed, we say, 'Oh, well, we had to walk to school uphill in the snow.'

John Mahan: Both ways.

Mike Patrick: [Laughter] Right. It's that mentality. Obviously you can see where this would improve patient care. I mean, because people are fresher, they're going to be thinking more clearly. Do you think that it has, I mean, are there pros and cons to the educational experience that the residents are receiving with these limits in place?

John Mahan: There certainly are. The concept that I could admit a child at 8am, and since I'm going to be there until the next day, I could watch that child evolve, get better from the treatments or potentially develop a complication, I would see that helping part of caring for that, is an educational value, and potentially, when you're restricted to shorter blocks of time, you may miss some of those.

23:03

The other concern about having less blocks of hours and restrictions is that sense of, we'll call it 'ownership' of the patient, that sense that, 'That's my patient. I'm going to be taking care of you for the next 28 hours. Everyone's going to come to me and I'm going to know about your child and I'll be able to help make sure that the right thing's done by your child.'

So the challenges of having restrictions is the need for us to go back and say, what are we doing intentionally to make sure that the residents are learning what they need to learn? What are we doing to make sure that the residents are very much engaged in learning?

And then also the concept of handovers, because when doctors are leaving, someone takes on the care of that patient, and that's that handover when I hand over my patients to you to take care. And that requires good communication, quality thinking, and is not something that comes naturally. So an important part of the latest ACGME regulations, the 2011 version, was further expectations and requirements about handover training.

24:14

So our residents now, we are required to provide them a formalized process for handovers. You don't just wing it; you've got to do it by a certain method. We are required to make sure they learn it and assess how well they do it. And these are good things, so I think…

Mike Patrick: That's why the 5 P's, right?

[Laughter]

John Mahan: Yes, the handover protocol. But these are good things, and we can look at that and say, in response to these ACGME changes, what can we do to preserve the education and, again, take better care of our families and patients and our trainees?

I think the jury is still out whether it has made a difference in patient outcomes, but I think it's common sense that someone in their 24th, 28th hour is more likely to make some mental mistakes or judgement mistakes that they wouldn't make in their fourth or eighth hour.

25:07

Mike Patrick: Yeah, absolutely.

In terms of passing pediatric boards or board scores, and we're going to get to exactly what that's all about here next, probably it's not really, those changes haven't been in place long enough to see if there's any correlation between board passing rates and how well pediatricians are trained in terms of their knowledge on those kinds of tests?

John Mahan: Yes, yes. In fact, I think actually the knowledge part in a sense is the easy part. Learning the facts and being able to remember them and apply them in a testing situation is actually the easier part of pediatric training. I'm not saying it's an easy part, but it's the easier part, and really, learning the clinical judgement, the ability to make diagnoses, the ability to spot changes in a patient, to be able to pick from the multitude of therapies the right one, that's a much more challenging kind of learning, and challenging to assess, and that's the part that, I think the concern has been raised, will less hours result in people with less-developed skills?

26:12

We are working very hard to make sure that doesn't happen, and I think given everyone's commitment to turning out quality pediatricians with strong skills, I really believe that it's not going to happen and that the individuals that are coming now will be as effective as when we could work them 120 hours.

Mike Patrick: Sure. And you make a good point that it's that judgement thing that's more difficult to learn, because in pediatrics, a lot of times kids don't follow the rule books and so what something is supposed to look like classically in a test and as it's described in a textbook, in a real life situation, there may be more subtle findings. And then you also have two siblings jumping around the room and pulling on your leg. I mean, those kinds of distractions that when they present the facts in a test, it's not quite the same as being in the room.

Tricia Lucin: I think, like Dr. Mahan said, that this will hopefully make things better, though, and I think that another important thing to remember is that even though we're not allowed to work 24, 30 hours in a row, we can only work 16, we work more months now and we work more shifts now. So the overall hours that we're working is probably very similar to previous, and I don't think our exposure will be hurt from these rules. So that is at least my hope, too. [Laughter]

27:22

Mike Patrick: Yeah.

John Mahan: And an interesting part, for example, with these latest rules, the second-year residents can work up to 28 hours, and one of the arguments has been made that, well, depending on the type of career and job you take, you may need to work extended hours. So we do need to train our young people to be able to do that, if that's required in their position.

Mike Patrick: Sure. Yeah.

Now, speaking of the pediatric board, there were three sets of medical boards that you had to take.

Tricia Lucin: Yes.

Mike Patrick: Two of them during medical school and one of them, then, during the first year of your residency, but that's just to satisfy state licensing requirements. What is the pediatric boards, then? What exactly is that?

28:01

John Mahan: The boards are a comprehensive knowledge test that takes actually a full day to complete, so it's about eight hours. To take the pediatric boards, you have to graduate from an accredited pediatric residency program, and the program director has to judge you as being qualified to take the boards. So you have to basically pass your three years.

With that, our graduates, then, have the opportunity to sit and take this quick, strenuous test. They really test all pediatric knowledge. It's a comprehensive examination, high stakes, and it's certainly something that is one of our goals as a training program to prepare our residents to do well on that exam because that exam is a marker of their knowledge and it is also an entry point into their career.

Mike Patrick: Sure. And it's not just a one-time test these days. Now you have to, I think it's every 10 years now. It was every seven and now it's every 10 that you have to take another test, and then there's a whole prescription of things that you have to do to maintain your board certification status.

29:08

John Mahan: Correct.

Mike Patrick: One of the things here in PediaCast that we talk about a lot is research. We take research topics and boil it down into terms that parents can understand and then how can you apply the results of this research to your own kids and to your own family, and we have research roundup shows where we do that, and we've had guests on where we talk about their research.

What about research opportunities during pediatric residency? Is that something that pediatric residents can get involved with if they wanted to, and particularly here at Nationwide Children's?

John Mahan: We certainly have those opportunities. The way our program is structured, like most internship, is a pretty intense clinically-loaded experience, so our interns rarely have that opportunity to take time out and do research. Although those that are interested certainly have the opportunity to start developing contacts and talking to potential faculty members to be advisers and start the planning process.

30:03

But during the second and third year of the pediatric residency, we are able to give our residents time for their professional development, and that's the opportunity to take electives in certain special areas, opportunities to do research, electives, or electives and things like global health, go overseas and have an experience there, advocacy, medical education.

So for our residents, we certainly have research opportunities. I can tell you the faculty enjoy having a young pediatric resident with enthusiasm and interest in a topic and begin that process of learning how to do investigation in that area. And we look at our residents as they graduate, somewhere between 25% and 40% then will actually volunteer to spend some of their elective time doing a research project.

Mike Patrick: Great. What would you say, as the program director, we've kind of inferred that this is a great pediatric residency training program and that you're exposed to a lot and you see a lot, what other things set the residency experience apart here at Nationwide Children's compared to other programs? I mean, folks in medical school right now who are seriously considering training in pediatrics, why should they come to Columbus, Ohio?

31:18

John Mahan: Well, our goal is to prepare our graduates to be very effective general pediatricians. Our goal is to give our graduates broad experience, make sure they have the knowledge and skills across the continuum that a pediatrician would ultimately be responsible for, with the idea that as a broadly-based and broadly-trained general pediatrician, you have the opportunity then to be an excellent general pediatrician in a community or in a clinic or pursue fellowship or what's called sub-speciality training in a specific area.

With our commitment to that broad training, we have very robust out-patient experiences that complement our large in-patient experiences. So our residents, for example, do three months in a primary care clinic during residency, which is above the minimal standards, because we believe that's a wonderful place for our residents to interact with families and children, develop some continuity relationships, and see primary care.

32:19

We've also added over the last decade-plus additional learning experience in an office. It's a pediatric education and community settings experience where our residents, at the beginning of second year, work with a general pediatrician, go to that office, spend an entire month, and they learn the business of pediatrics, how the office works, and then go back to that same office with that same faculty member about 24 times, 24 afternoons, second and third year.

So our residents get great exposure to office pediatrics, which is a little complementary but a bit different than what we see in clinic pediatrics. That's part of our commitment in what we think is important about a residency program.

33:00

I would say the other piece is really our ability to provide the broad array of elective experiences and allow our residents to personalize their training. We typically have 10 to 15 residents a year doing a national health elective where they go overseas and provide health care and learn about the challenges of providing health care overseas. We have individuals do advocacy projects, do medical education projects so they can broaden their experiences during residency training to prepare themselves for their eventual career.

Mike Patrick: Speaking of their career, obviously, the first thing that comes to mind when parents think of pediatricians is the office where they take their kid, but there are a lot of other career opportunities for folks who finish a pediatric residency training program. What are some of the other things that folks could do with this training?

John Mahan: In addition to the pediatrician that works in the clinic or in the private office setting, we now see a number of our graduates going into positions that are called a hospitalist position where they have primary responsibility to take care of hospitalized patients.

34:08

One of the trends in general pediatrics is for the office practitioners to focus on the office issues of their patients, but when there's children need to be admitted to the hospital to have their care assumed by hospitalist pediatricians. So these are general pediatricians with broad training who can focus on the hospital part of the course.

And part of the benefit of that is the hospitalist can focus on the hospital issues, does not have the additional out-patient issues pulling them away, and studies have shown that a child taken care of by a hospitalist actually has a shorter length of stay and can actually get better quality care because of that focus by the hospitalist.

We also have some of our graduates work in what's called urgent care, so work in these areas that are not quite as intense as emergency medicine departments but provide acute care.

And then, about 40% of our graduates, 50% some years, pursue fellowship training, sub-specialty training. In that avenue, they seek additional training, usually three more years, in a sub-specialty. That might be pediatric cardiology, gastroenterology, nephrology, endocrinology, neonatology, emergency medicine.

35:19

So these are special programs for three additional years of training. And those individuals, when they complete that successfully, then become board-eligible in that sub-specialty as well as what they accomplished in terms of general pediatrics.

Mike Patrick: So another set of boards.

John Mahan: Another three years.

Tricia Lucin: They never end.

[Laughter]

John Mahan: Yeah, another new body of knowledge and another set of boards, that's right.

Mike Patrick: Right. So with all of these opportunities before you, Dr. Lucin, have you given thought to what your plans are after your residency is over?

Tricia Lucin: Well, I've certainly given lots of thought, and I'm not fully decided. I have really liked many of my rotations, but I think I have a very difficult time choosing amongst them and I think that it would be very hard for me to cut out any one thing.

36:02

I think that probably I will be a hospitalist. I'm very drawn to the in-patient medicine, the more acute care, but I would like to see a wide array of children in lots of different sorts of things. So if I had to pick today, I would be a hospitalist.

Mike Patrick: But you still have some time.

Tricia Lucin: I do, and I still have a couple of things that I'm kicking around. [Laughter]

Mike Patrick: Now, in terms of a fellow, then, what exactly is that role? When you say you're entering a fellowship, what does a fellowship look like?

John Mahan: Just as a pediatric resident spends three years learning pediatrics, a pediatric fellow in a sub-specialty area spends three additional years learning that discipline and learning it at a much higher level.

For example, a pediatric kidney specialist, a pediatric nephrology fellow, will learn more knowledge about pediatric kidney disorders, they will learn the skills that are required to take care of the kinds of problems you see in the pediatric kidney world, so children with acute renal failure, children that need hemodialysis, very specialized techniques that are beyond the level of a general pediatrician and a general pediatric resident.

37:06

And then, during that three years of training, there are additional requirements and opportunities to develop academic skills to do research, to develop projects so that when those individuals are done that fellowship training, they are able to not only take their fellowship boards and become board-certified but also move on to a career in that sub-specialty.

Occasionally, you'll see an individual do a fellowship and decide, 'I did it, but I'd rather be a general pediatrician,' or 'I'd rather be a hospitalist.' So those opportunities are always there to take different career paths. But for the most part, if someone's going to spend three years in additional training, they're making a big investment and they're going to pursue a career in that area.

Mike Patrick: So typically, if you were to want to do research in pediatrics, you would probably follow that: I'm going to do a residency, then I'm going to do a fellowship, and during my fellowship I'm going to start to get involved with some research in that sub-specialty, and then once I'm practicing in that sub-specialty in an academic institution, then that's really where I'm going to continue to do, possibly be a pediatric researcher at that point.

38:14

John Mahan: Potentially, although we have pediatric sub-specialists that spend a large majority of their time doing patient care, because there are certainly significant patient care needs. And we even now have, just in the last two years, opened up a general pediatrics fellowship so that an individual can spend additional time learning more skills around general pediatrics and doing research in general pediatric questions.

Mike Patrick: Sure. What about being a professor of pediatrics? We had mentioned you are a professor of pediatrics at the Ohio State University. What does that pathway look like to becoming a professor?

John Mahan: Well, it's always about pathways. Starting off at an academic medical career, typically the entry level position is called assistant professor, and that's right after your training.

39:00

By demonstrating excellence in patient care and academic work and teaching, you get the opportunity to be promoted to an associate professor. And typically to become an associate professor beyond that expectations of excellence, you should also be developing some engagement nationally, so you should be demonstrating that you have things that you contribute to your field beyond just your local hospital.

And then, as an associate professor, then the bar is higher to become a full professor. The requirements are to do more substantial work, more scholarly work, so publications, for example, and presentations at national meetings. And based on a vote of your peers, the professors in your medical school, as individuals accomplish these things, they get the opportunity then to be promoted to become a full professor. And for most of us, that's really required doing excellent work in clinical area, taking care of patients well, teaching well, and doing research and publishing.

40:07

Mike Patrick: Great.

I'm going to shift gears here just a little bit. There are other pathways to taking care of patients, and what we're seeing more and more, especially like in urgent cares and in some doctors' offices, the presence of nurse practitioners, and in other areas of the country, here in the Midwest, I think we see a lot more nurse practitioners than physician assistants, but in some other areas of the country you see more physician assistants than nurse practitioners, depending on what programs are available in different areas. How does their scope of practice differ from what we're talking about in terms of being a pediatrician?

John Mahan: There's nurse practitioners and physician assistants work under the direction of a licensed physician, so their scope of work is very much defined by their relationship with their supervising physician, and those are laid out by different state requirements.

41:03

Those individuals are trained and typically get very good clinical training in that area, but they are not adjudged capable of practicing independently, so they have to work for somebody. In that sense, they are able to provide significant amount of care but have that additional oversight and additional connection to a practicing physician.

It becomes a very strong and valuable construct because with having nurse practitioners and having physicians assistants, we can extend our ability to take care of more children, do a very good job taking care of the children, and still ensure that top quality care is being provided.

Mike Patrick: Yep. Here at Nationwide Children's, there's always physicians around, so in my work in the emergency department and the urgent cares, when we have nurse practitioners, if they have any questions, if there's something that they haven't seen before, there's always a physician that's immediately available.

42:00

But there are instances where parents may go to an urgent care center and the only person there is a nurse practitioner. And I don't want to put you on the spot, but I think that parents should be very careful about, if a parent is concerned and the practitioner that they're seeing may not be as equally concerned, you know what I'm saying, that they should probably seek care somewhere where they're going to have a physician or a nurse practitioner that has strong support. Would you agree with that?

John Mahan: Certainly. And a nurse practitioner, for example, in an offsite kind of clinic technically has a physician supervisor, but that physician is not onsite.

Mike Patrick: Yeah. Like a little grocery store clinic.

John Mahan: And phone supervision is very different than onsite supervision. So what you described at Nationwide Children's, our nurse practitioners, for example, have physicians that they can grab immediately to come look at a patient. Parents have the opportunity to seek a physician immediately if they are concerned that something is amiss, something's being done incorrectly.

43:04

So the oversight is much stronger in our kind of system where physicians are actually physically present, and I think it's a better model.

Mike Patrick: Yeah. So if you're in Central Ohio, and obviously we have listeners from all over the United States, but if you are in Central Ohio and you need a pediatric urgent care, you're really better off coming to Nationwide Children's. I'll put that plug in. I'm allowed to do that.

[Laughter]

John Mahan: And we would agree.

Tricia Lucin: Yes.

Mike Patrick: Let's also put a plug in for the Pediatric Residency Training Program; as just in a nutshell, why should medical students consider our program? If they're out there right now and they've heard this program and they're really trying to decide between two different ones, I know I've asked you this question before, but just to sum it up, maybe Dr. Lucin this time, in your experience so far, would you recommend that the other medical students choose the path that you have chosen?

Tricia Lucin: Sure. When I was looking for a school, I was really only looking at top-tier schools. I wanted the best education I could come by.

44:00

And then, during interviews, you get to know the programs a little bit better than you do just on paper, and I think that the big things that drew me back to Ohio are, number one, the people. Everybody says the Midwesterners are nice, but there is such a camaraderie amongst the classes and you're never without help if you need it.

I think another big thing is not only do we have all the sub-specialties that you can experience but we have so many support staff. We have respiratory therapists and dieticians and psychologists, and just really anything that you need is available, and most of those people are very willing and able to teach you. So the scope of your exposure here is just immense.

Mike Patrick: Yeah. And a beautiful new facility.

Tricia Lucin: It is lovely.

[Laughter]

John Mahan: Yes, it is, and very family-centered in its inception and in its design and execution.

And I would go back a step and say the reason that a medical student should come here is because what we're about is taking the best care of our children, of our patients, and that's our responsibility, that's our privilege.

45:06

And in my view, the best way to learn is by taking best care of the patients. So our task as directors of these training programs and faculty is to put our residents at a position where they're going to take the best care of the patients, they're going to see the best care, they're going to deliver the best care, and by doing that, then, learn the best way, and it's really a false choice to say, 'By doing this without patients, it hurt my learning.' No. Our job is to put it together so that these complement each other.

And what I tell applicants when they want to look at our program is our task as program directors and faculty is to make sure that the children get the best care possible by having the best residents and teaching them and training them up, and that's the kind of place you want to come to.

We have phenomenal resources and wonderful community support, so we're able to offer the breadth of learning experiences over 375 pediatric faculty, the wonderful electives and opportunities like that because we have these great resources.

46:08

Mike Patrick: Yeah. I think we're close to seeing a million children come through the Nationwide Children's system every year, so you definitely see everything, and there's that culture of support and the importance placed on learning just really makes this a special place.

John Mahan: Yeah. And, you know, just even in the last decade, back in 2002 we had, I believe it was nine or 10 fellowship programs in pediatrics. We just opened our 29th, covering pediatric orthopedics, pediatric dentistry, pediatric urology, pediatric psychology, as well as cardiology and nephrology. So we really are committed to training the next generation, and we are really training them because we believe that's the care model that delivers the best care to the kids.

Mike Patrick: So where do medical students, how can they find out more about the program here at Nationwide Children's? What's the best source?

Tricia Lucin: Well, I think there's lots of great resources on just the website. You can click on the 'Resident Education' link under the Nationwide Children's Hospital website and there are tons of resources on what to expect and how to apply and who to contact. Those are great resources.

47:11

And then I think if you are in town, if you are around, you can certainly just come up to the office and meet people. I think just almost everybody is willing to help, and we certainly have students who come through, as I said, in shadow or spend a day with us to see what it's like.

Mike Patrick: Sure. And we'll put a link to the Pediatric Residency Training Program in the Show Notes for this episode, which is 220, at pediacast.org so people can find it easily there as well.

We really want to thank Dr. John Mahan and Dr. Tricia Lucin for joining us in the studio today. I really, really appreciate you guys stopping by.

Tricia Lucin: Thanks for having us.

John Mahan: Our pleasure.

Mike Patrick: And also thanks to all of you for taking time out of your day to listen to PediaCast and make us a part of it. We really appreciate it.

I do want to remind you that iTunes reviews are helpful, as are links on your webpages and mentions in your blogs, on Facebook, in your tweets and on Google+. Be sure to join our community by 'liking' PediaCast on Facebook, following us on Twitter, tweeting with hashtag #pediacast, and hanging out with us on Google+. And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show.

48:12

We'd also appreciate you telling your family, friends and neighbors about the program, and don't forget to talk us up with your child's doctor at your next well checkup or sick office visit.

I also want to remind you, if there is a topic that you'd like to hear about or you have a question for us here at PediaCast, just go to the 'Contact' page at pediacast.org. You can also email pediacast@gmail.com or you can call the voice line at 347-404-KIDS, 347-404-K-I-D-S.

And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!

[Music]

49:00

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

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