Postgraduate Training in
Ambulatory Pediatrics
Program Evaluation
Alvin H. Novack, MD, Kenneth G. Reeb, MD
\s=b\ Ambulatory pediatric, adolescent
medicine, and child development fellow-
ship programs listed in the Ambulatory
Pediatric Association (APA) newsletter
were surveyed to gather information about
the programs for prospective fellows, to
develop a descriptive summary, and to
determine the extent to which programs
adhere to APA guidelines. Number and
types of positions offered, criteria for
admission to programs, program educa-
tional objectives and activities, and career
choice of graduates were examined for
the 73 programs offering 132 fellowship
positions in 1976 to 1977. In general, APA
guidelines were followed. Programs em-
phasized patient care experience in con-
trast to health care administration, re-
search, and teaching.
(Am J Dis Child 133:687-690, 1979)
the graduate
25 years,
During
from
past
medical education has
changed
specialty (surgery, pediatrics,
internal medicine, etc) or residency
training to include subspecialty (fel¬
lowship) training. Despite the growth
in numbers and types of fellowship
From the Department of Pediatrics, Case
Western Reserve University, and the Cleveland
Metropolitan General Hospital (Dr Novack), and
the Rainbow Babies' and Children's Hospital (Dr
Reeb), Cleveland.
Reprint requests to Department of Pediatrics,
Cleveland Metropolitan General Hospital, 3395
Scranton Rd, Cleveland, OH 44109 (Dr Novack).
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training programs relatively, little
data are available about the programs
themselves or their trainees. Consid¬
erable attention has been focused on
the educational objectives and activi¬
ties of general residency programs,
but fellowship programs have not
undergone this degree of scrutiny.
In 1972, Mason1 reported the man¬
power needs of different specialties.
He examined the physician-popula¬
tion ratio of specialties and subspe-
cialties and compared existing ratios
to the optimum ratios used by prepaid
health plans to staff their programs.
Specialists were not subclassified, and
all internists and pediatricians were
considered as primary care practition¬
ers. Thus, insight into numbers, type,
and distribution of pediatrie and
internal medicine primary care and
subspecialist physicians was not dis¬
cernable from this study. Knowles2
also noted the scarcity of data about
subspecialties and their related train¬
ing programs. Exceptions are recent
reports assessing training programs
and manpower needs in pediatrie
cardiology and adolescent medi¬
cine.35
Finally, the Ambulatory Pediatrie
Association (APA) investigated am¬
bulatory pediatrie fellowship pro¬
grams in the United States and
Canada using questionnaire surveys
of directors of fellowship programs
wishing to list their programs in the
association's special newsletter on
fellowships. The results of the first
survey were reported previously."
This report is an attempt to docu¬
ment the present efforts of the APA
to assess training programs in ambu¬
latory pediatrics and the related areas
of adolescent medicine and child
development. The methodology used
to gather the data may provide a
model for other subspecialties.
METHODOLOGY
Questionnaires were distributed in No¬
vember 1975 to 212 pediatrie departmental
chairmen and directors of programs pre¬
viously listed in the APA newsletter.
Announcements of the planned listing
were published in the APA newsletter.
Directors of programs not previously listed
in the APA newsletter either requested
questionnaires in response to these an¬
nouncements or submitted completed ques¬
tionnaires obtained from the departmental
chairmen. Programs not submitting a
completed questionnaire were not included
in the APA listing nor are they repre¬
sented in this report. Thus, the data
contained in this report do not represent
the universe of programs (a systematic
survey of departmental chairmen to deter¬
mine the universe of programs was not
attempted until 1978) but is concerned with
 those programs that submitted a com¬
pleted questionnaire prior to February
1976.
An exact determination of the repre¬
sentativeness of the sample of ambulatory
pediatrie programs was not possible. There
are no complete listings of ambulatory
pediatrie fellowship programs. An attempt
was made to compare the sample reported
here with the fellowship listing in the
Journal of Pediatrics. However, such a
comparison was not possible because the
latter listing uses different categories and
includes second- and third-year residency
training programs.
This report probably under-represents
adolescent fellowship programs since the
Society for Adolescent Medicine reported
on 28 adolescent programs training 46
fellows.4
Initial responses to the questionnaire
were reviewed, and incomplete question¬
naires were returned with specific instruc¬
tions to allow for their completion. The
goal of the survey was to determine the
following: First, is general characteristics
of ambulatory pediatrie, child develop¬
ment, and adolescent fellowship programs
(for example, sponsoring institution, medi¬
cal school affiliation, number of positions
offered, stipends, etc) listed in the APA
newsletter. Second, is the criteria for
acceptance of fellows to training programs.
Third, is the educational objectives of
fellowship programs. A rating scale,
designed to reflect the reported relative
emphasis placed on the educational objec¬
tives in each of the four content area
categories (patient care, health care ad¬
ministration, research, and teaching) was
developed. Respondents could report an
emphasis on a five-point scale between
zero (no emphasis) and four (extensive
emphasis). The emphasis ratings for the
educational objectives were determined by
dividing the total number of points
reported in a category by the total number
of points possible. For example, the patient
care category included seven objectives for
a possible emphasis rating of 28 points. If
21 emphasis points were reported, the
emphasis rating was 75.0 (21 divided by
28 x 100 75.0).
Fourth, is the types of program activities
-
and the time devoted to each. Information
about program activities was elicited by
presenting respondents with a list of activ¬
ities and asking them to indicate whether a
particular activity was required, elective,
or not offered. Respondents were also
asked to estimate the time in hours/week
allocated to each activity, but unfortunate¬
ly this latter question was not routinely
completed. Program activity emphasis was
estimated by assigning scores of 1.0, 0.5,
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and 0.0, respectively, to the required, elec¬
tive, and not-offered responses. Emphasis
ratings were calculated for each of the four
activity areas (patient care, health care
administration, research, and teaching) by
dividing the numerical value of the
responses in that area by the maximum
possible score. For example, requiring
three activities, offering one elective, and
not offering a fifth of the five activities in
the administration area received an em¬
phasis rating of 3 + 0.5 + 0/5 x 100 =
70.0.
Fifth, is the APA guidelines include the
following four categories: patient care,
administration of health care, research,
and teaching. The questionnaire was
constructed to incorporate the guidelines
in each of the four categories, and the data
were examined to determine the degree to
which the fellowship programs adhered to
these guidelines. Sixth, is the posttraining
careers of graduates.
RESULTS
Seventy-three program directors
submitted completed questionnaires.
The programs were divided into the
following three groups: adolescent
(N 13, 17.8%), pediatrie ambulatory
=
(N 53, 72.6%), and child develop¬
=
ment (N 7, 9.6%). Only five pro¬
=
grams were not primarily associated
with a university medical center.
General Characteristics
One hundred and thirty-two fellow¬
ship positions were offered by the 73
programs during the academic year
1976 to 1977. Thirteen adolescent
programs offered 14 fellowship posi¬
tions; 53 ambulatory pediatrie pro¬
grams offered 102 fellowship posi¬
tions; and the seven child development
programs offered 16 positions. During
the academic year 1975 to 1976, 128
fellowship positions were filled. There
are differences in the number of avail¬
able and filled positions when 1975 to
1976 and 1976 to 1977 data are
compared. Adolescent programs of¬
fered fewer fellowship positions in
1976 to 1977 than were filled in 1975 to
1976. Ambulatory pediatrie and child
development programs offered more
positions during 1976 to 1977 than
were filled in 1975 to 1976.
Slightly less than half of the
programs offer one year of training,
whereas the majority offer two or
more years of fellowship training. All
child development programs are for
two years, whereas the adolescent
programs are equally divided between
one-year and two-year programs.
Program Criteria For
Acceptance of Fellows
Requirements for entry into the
programs were similar for all three
types of programs. United States
citizenship (or Canadian citizenship
for Canadian programs) was required
by 31% of the programs. Half of the
programs required that trainees be
eligible for licensure to practice medi¬
cine, and only one fifth required state
licensure. All programs required two
or more years of previous pediatrie
training.
Educational Objectives
The educational emphasis placed on
each of the four categories (patient
care, health care administration, re¬
search, and teaching) is represented
by a score for that category (Table 1).
A one-way analysis of variance was
used to analyze the data.7 There were
no statistical differences among pro¬
gram types for all four categories.
Statistical comparison of the empha¬
sis rating among categories was not
possible, but all three program types
seemed to place greater emphasis on
patient care educational objectives
and similar emphasis on the other
three categories with only minor vari¬
ations among program types.
Program activity and educational
objective data were analyzed similarly
(Table 2). There was a statistical
difference among program types for
patient care activities, and there
seemed to be less emphasis on teach¬
ing activities for all program types.
The differences among program types
for the other categories were not
statistically different.
Patient Care
The size of the patient population
assigned to fellows for continuing
care experiences was surveyed. Al¬
most 80% of the adolescent programs
required trainees to follow 100 or
fewer patients, whereas one fifth of
the programs require their fellows to
follow 100 to 300 patients. Examina¬
tion of ambulatory pediatrie programs
 Table 1 .—Educational Objectives by Program Type low for all three program types. A
correlation matrix showed a high posi¬
Program Patient Health Care Research, Teaching, tive correlation between administra¬
Type Care, mean Administration, mean mean mean
Adolescent (N 13) 77.5
=
53.6 55.4* 65.3* tive (0.617) and research (0.648) educa¬
Ambulatory pediatrics tional objectives and activities. There
(N 53) 74.9 58.2 55.9 58.3* was less correlation for educational
=

Child development
(N 7) =
79.5 63.8 63.6 60.1"
objectives and activities for teaching
Total (N 73) = 75.8 57.9 55.6 59.6 (0.302) especially for group instruction
*N 1 for these cells.
(lay education, 0.300), and almost no
=

—
correlation for patient care (0.114).
The lack of correlation between
Table 2.—Program Activities by Program Type patient care educational objectives
and activities can be attributed to the
Program Patient* Health Care Research, Teaching,
Type Care, mean Administration, mean mean mean child development and to a lesser
Adolescent (N 13) 77=
55 58 29 extent the adolescent programs.
Ambulatory pediatrics
(N 53) =
83 611 57 35 Research Activities
Child development
62 70 74
Research activities were subdivided
(N 7) =
50
Total (N 73) = 79.6 61 59 36
into traditional and nontraditional
*P =
.05; F =
5.36.
categories. The nontraditional catego¬
tN = 1 for this cell. ry included areas of investigation that
-
could be broadly categorized as health
services research. The traditional cat¬
Table 3.—Careers of Graduates Trained in Past Five Years by Program Type
egory included what is generally
Ambulatory Child considered clinical research. When the
Adolescent Pediatrics Development Total
three program types were compared,
Careers of Graduates (N = 95), % (N = 225), % (N = 45), % (N =
364), %
Armed services 7.4 4.0 4.4 they were significantly different with
Private practice of pediat¬ adolescent programs having lower
rics 22.1 30.8 42.2 29.9 scores (0.17 ± 0.17) than child devel¬
Outpatient department of
university hospitals 32.6 21.4 6.7 22.5
opment (0.30 ± 0.15) or ambulatory
Outpatient department of
(0.40 ± 0.18) for nontraditional re¬
other hospitals 3.2 10.3 search activities (P < .05).
Comprehensive care pro¬ Careers
grams in poor commu¬
nities 3.2 15.6 2.2 10.7
There have been 95 adolescent, 224
Full-time medical care re¬
search 11.6 4.5 8.9 6.9 ambulatory pediatrics, and 45 child
Other 15.8 3.6 178 8.5 development fellows trained by the 73
Still In training or Incom¬ programs during the five years prior
plete data reported 4.1 9.8 17.8 9.4 to the survey. The career patterns of
these 364 graduates are shown in
showed that 38% require fellows to teaching and to a lesser extent health Table 3. Thirty percent of all fellows
provide continuing for 100 to 300care care administration and research are are engaged in the private practice of
patients. Child development fellow¬ given less emphasis than suggested by pediatrics, and 22.5% are employed by
ship programs differed considerably the guidelines. The determination of outpatient departments of university
from adolescent and pediatrie ambula¬ substantial deficiencies in these areas hospitals; almost 11% are actively-
tory programs requiring continuous was not within the scope of this engaged in comprehensive care pro¬
care experiences for fewer patients. study. grams in poor communities, and 6.9%
Many programs (approximately two As noted previously, scores were are involved in some medical care
thirds) require fellows to take some computed both for program educa¬ research in an academic environ¬
night call. Adolescent programs aver¬ tional objectives and activities. The ment.
age two nights on call per week; data were analyzed to determine the Graduates of adolescent training
ambulatory pediatrie programs and relationship between educational ob¬ programs are more often employed in
child development programs average jectives and program activities for outpatient departments of university
one night of call per week. each of the four categories and the hospitals, and almost 12% are em¬
three program types. ployed by an academic institution and
Adherence to Guidelines In general, program activities and do some medical care research. Very
In general, the programs adhered to objectives were similar. The emphasis few graduates are employed by outpa¬
the APA guidelines for pediatrie placed on the activity of teaching both tient departments of hospitals other
ambulatory fellowships. It seems lay and professional groups was quite than university hospitals or in com-

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 prehensive care programs for poor
people. Twenty-two percent of the
graduates of adolescent programs are
engaged in the private practice of
pediatrics. Graduates of pediatrie am¬
bulatory programs, on the other hand,
are more often engaged in private
practice, outpatient departments, and
comprehensive care programs, where¬
as only 4.5% are in full-time medical
care research. Almost half of the child
development fellows are in private
practice, and 18% are in a variety of
programs not easily categorized.
COMMENT
This survey and its predecessor,
have been useful in providing infor¬
mation about the nature of fellowship
training programs in ambulatory pe¬
diatrics and the related areas of
adolescent medicine and child devel¬
opment. Information has been ob¬
tained concerning characteristics of
trainees, the orientation and nature of
the education programs, and the even¬
tual careers of program graduates.
This information has been dissemi¬
nated to members of the APA and has
been used by program directors and
others planning programs as well as
prospective trainees interested in
information about specific programs.
The data have been helpful to the
leadership of the APA, which is inter¬
ested in monitoring the quality and
quantity of ambulatory fellowship
training in the interest of upgrading
the quality of programs.
Error in Last Entry in Subjects Column in Table.\p=n-\Inthe article titled "RBC Surface Pits
in the Sickle Hemoglobinopathies," published in the May Journal (133:526-527,1979), an
error occurred in the final entry in the "Subjects" column in the Table. It should read
"Hemoglobin S-C disease" and not "Sickle cell disease."
Downloaded From: by a The Houston Academy of Medicine User on 11/26/2017
The established guidelines of the
APA provide a useful standard
against which programs can be com¬
pared. At this time, we have no meth¬
od for validating the accuracy of the
information obtained through the
mechanism of self-reporting by pro¬
gram directors. We surmise that the
degree of reliability differs with the
information requested. For instance,
the accuracy of information obtained
by questionnaires about educational
objectives should compare favorably
with other data-gathering methods.
On the other hand, information about
the careers of graduates might better
be obtained by surveying the grad¬
uates directly. Information about
time devoted to different activities
would probably be best obtained by
direct observation.
The inability to determine the
universe of graduate training pro¬
grams in the three areas (child devel¬
opment, adolescent medicine, and pe¬
diatrie ambulatory) represents a con¬
straint in making any generalizations
from these data. The programs re¬
sponding to the survey represent a
biased sample since programs more
closely adhering to APA guidelines
were more likely to respond. In the
future, an attempt will be made to
develop a listing of all fellowship
programs providing training in ambu¬
latory pediatrics, child development,
and adolescent medicine. This will be
accomplished by surveying pediatrie
departmental chairmen.
CORRECTION
Our intent is to continue to explore
the value of the present method of
monitoring ambulatory fellowship
programs. An effort will be made to
validate future questionnaires with
selected on-site observations. Based
on our finding that little information
about fellowship training is available,
we recommend that other pediatrie
subspecialties develop a unified re¬
porting system to evaluate programs
and trainees. A necessary first step is
a willingness on the part of the pedi¬
atrie subspecialties to gather data
about their training programs and
trainees. If such were the case, devel¬
opment of a unified reporting system
could be achieved.
The project was supported in part by the
Ambulatory Pediatrie Association.
Margaret C. Heagarty, MD, and Robert A.
Hoekelman, MD, helped in the preparation of this
manuscript. Judith Lovecchio and Barbara
McVicker also assisted in this project.
References
1. Mason HR: Manpower needs by specialty.
JAMA 219:1621-1626, 1972.
2. Knowles JH: The quantity and quality of
medical manpower: A review of medicine's
current efforts. J Med Educ 44:81-118, 1969.
3. Adams FH, Blumenthal S, DuShane JW, et
al: Manpower and training requirements in pedi-
atric cardiology. Pediatrics 51:813, 1975.
4. Hofmann AD: Fellowships in adolescent
medicine. Soc Adolescent Med Newsletter 8:2-31,
1972.
5. Hofmann AD: Fellowships in adolescent
medicine. J Pediatr 83:512-514, 1973.
6. Heagarty MC, Fischbarg S: Ambulatory
pediatric fellowship programs. Am J Dis Child
129:29-31, 1975.
7. Rahn AK: Bowie Medical Statistics, New
York, Greene and Stratton, 1972, pp 178-180.