Section A

Promoting Generalism in the Pediatric Clerkship

Jerold C. Woodhead, M.D.

The core curriculum for the pediatric clerkship has been developed by the Council on Medical Student Education in pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA) to emphasize the clinical activities of the general pediatrician. The rationale for emphasizing generalism is straightforward: the principle need for physicians lies in the primary care or generalist disciplines, which includes pediatrics. In order to make informed career decisions, students must have opportunities to experience the generalist disciplines, including general pediatrics. Medical students beginning the study of pediatrics must be provided the opportunity to develop a solid foundation in the basics and must also have role models who can demonstrate the intellectual, personal and social satisfaction of general pediatric practice. An emphasis on generalism does not mean, however, that the contributions of Pediatric subspecialists or the importance of their disciplines will be ignored or devalued.

An individual student's career choice initially involves selection of a discipline for residency training, which in turn is influenced by the student's experience in the clerkship. The Pediatric clerkship, therefore, should provide the kind of clinical experience that will demonstrate the excitement and challenge of primary care for children and adolescents and will encourage students who have an interest in primary care to consider residencies in pediatrics. The curriculum and resource manual developed by the COMSEP/APA working group and its advisors directs the core clerkship in pediatrics towards generalism by:

• emphasizing the knowledge base, the clinical skills and the professional behaviors of general pediatricians,
• encouraging an increase in the activity of general pediatricians as teachers, role models and mentors,
• emphasizing the "general" that lies at the heart of the "specialty" while maintaining the strong teaching and mentoring skills of subspecialists,
• promoting clinical problem solving and independent learning,
• directing attention to common acute and chronic clinical problems, and
• focusing on the clinical skills unique to the care of children and adolescents.

This curriculum assumes that students beginning the study of pediatrics will have had little, if any, prior experience with children and adolescents. A six-week clerkship can only introduce students to the breadth of a general pediatrician's clinical activity. If the Pediatric clerkship is firmly grounded in the basics and emphasizes acquisition of a broadly based education by students, those students who wish to acquire the depth of knowledge and the skills necessary for independent assessment and management of clinical problems in pediatrics will be encouraged to seek further training in pediatrics.

Learning activities during the clerkship will most profitably be directed towards basic principles: growth and development, behavior, health supervision, and common clinical problems. The clinical activity of the general pediatrician, whether in an academic or a community setting, is the foundation of the clerkship curriculum, although subspecialists have important roles in teaching. The curriculum is designed to challenge students by exposing them to intellectually stimulating clinical problems and by asking them to develop approaches to solve these problems. By emphasizing these clinical skills, the curriculum provides students with the opportunity to gain an appreciation of the general pediatrician, who must understand the importance of prevention, must have a strong background in health supervision, and must be prepared to manage "unlabeled," acutely ill patients. This latter activity challenges pediatricians to have a broad knowledge base and to recognize the limits of their skills and knowledge. The general pediatrician's interactions with subspecialists should further demonstrate for students the breadth of the generalist's practice. Exposure to pediatric generalists and specialists during medical school (and residency) must be assured if breadth of knowledge and clinical acumen are to be developed.

In order to emphasize general pediatrics and at the same time utilize optimally all of the skilled, dedicated faculty members in subspecialty divisions, most departments of pediatrics will find it necessary to restructure the content and the style of medical student teaching. For example:

• Outpatient settings will need to be utilized more than is currently done for student teaching, with attention paid to time (and, occasionally, resource) limitations. This curriculum encourages 50% outpatient experiences.
• Community-based practices will become increasingly more important as sites for student education in pediatrics, but must be utilized with a formal curriculum and with faculty development to ensure that they function as appropriate learning environments.
• Health supervision and common acute and chronic problems will be the issues most amenable to teaching in a general pediatric outpatient setting, whether in the medical center or the community.
• subspecialty activities can demonstrate for the student those aspects of a given subspecialty which are appropriate to the practice of a general pediatrician and those which will require the active involvement of a subspecialist through referral or consultation
• Subspecialty clinical encounters should also be used to teach about the effects of acute or chronic illness on normal growth and development and on family interactions.
• Teachers other than physicians may have increasingly important roles in student education (e.g. nurses, social workers, dietitians, speech and language specialists, psychologists and many others) not only to provide a perspective different from the traditional physician-centered one, but also to emphasize the importance of team management of both healthy children and those with more complicated, chronic problems.
• Activities and sites not traditionally included in clinical training may prove to have great value for medical student education in pediatrics: daycare centers, schools, child life programs, churches and health outreach programs, for example, might be integrated into clerkships as sites for student education.

General pediatrics has not been the focus of many clerkships because these clerkships typically are based in academic medical centers where the strength of pediatric departments lies in the subspecialty divisions. In such programs, subspecialty divisions provide most of the opportunities for clinical interactions because their faculty members outnumber generalists. At some medical schools community-based pediatricians have not participated in student education for reasons that vary from restrictions imposed by academic departments to restrictions in pediatricians' offices imposed by lack of time, space and financial resources. Inpatient services, the traditional site for medical student education in the past, have been subspecialty oriented in many medical centers. Direct care of patients has been relatively easy to provide for students on inpatient services until recent changes in medical practice have drastically reduced the importance of the inpatient setting as a site for primary and secondary level medical care. The new emphasis on the outpatient clinical encounter will challenge most clerkships to identify new sites where students may participate actively in patient care activities. While observation is an important aspect of learning, it can be justified only as a small part of any clerkship: active, direct, "hands on" participation by students in patient care is key to a successful clinical learning experience.

Equally important in this learning experience are thoughtful teaching, supervision and evaluation of students by experienced faculty preceptors. None of these activities is innate; all require explicit faculty development activities which, in turn, demand time, resources and experienced leaders. No longer can faculty turn students loose on an inpatient service with a textbook and vague directions to "learn clinical medicine." Because a curriculum is much more than a list of important facts that must be learned, faculty must understand the intent and the content of the curriculum. Faculty must allow (and expect) students to be adult learners, actively involved in the educational process. They also must have realistic expectations for medical student performance in the introductory pediatric clerkship and must know how to assist students to acquire the knowledge, behaviors and skills that they are expected to master. Effective, timely feedback about student performance is an ability that many faculty members need to work on, but is vital to a successful student teaching program. Faculty will find it necessary to reflect on their own clinical activities because, as teachers, faculty serve primarily as role models of professional conduct and of clinical problem-solving. Creative teaching will be demanded of all preceptors in outpatient settings because of the time constraints inherent to the outpatient clinical encounter.

Residents have an important, although largely unstructured role in medical student education, especially on inpatient services. The new emphasis on outpatient management will take residents from the inpatient services and place them in clinics and community offices. Resident supervision and teaching of students, thus, may decrease, although residents undoubtedly will be called upon to provide student supervision in some outpatient sites. Whether on the inpatient service or in the outpatient clinic, residents will need formal instruction about their roles as teachers and evaluators of students. Activities similar to those provided for faculty development will be necessary to ensure that residents can supervise and teach effectively.

Students will have the corresponding responsibility to be adult learners, which will occur only if it is expected of them. They must develop and perfect independent learning skills and demonstrate enthusiasm, self-motivation, and willingness to work as part of a team. Students will also need to demonstrate the ability to integrate newly acquired knowledge with their newly developing clinical skills. Responsible clinical behavior has always been expected of students, but the outpatient environment will place new demands on students earlier in their clinical training than was the case when the inpatient service was the principal site for the first experience in pediatrics. Flexibility and a willingness to take advantage of the opportunities and to respect the constraints of the outpatient clinical encounter will be essential, because opportunities to spend several hours with patients taking detailed histories and performing complete physical examinations will be severely curtailed as the inpatient census drops.

Each institution will find it necessary to develop its own approach to promoting generalism in pediatrics and in the overall medical school curriculum. Since the development of clinical problem-solving skills is crucial to the education of all physicians, this aspect of medical education should form the core of undergraduate medical education, including the "generalist clerkships." A general emphasis on adult learning might best begin with problem-solving during the preclinical years either in a distinct course or as part of "clinical correlation" in basic science courses. If class size permits, problem- solving as the focus for the entire curriculum might be desirable. During the pediatric clerkship (and in other "generalist" clerkships) in addition to the clinical problems presented by a student's assigned patients, opportunities for clinical problem solving could include such activities as oral or written case evaluations, standardized patients and role playing exercises. Examination and evaluation might include all of the above plus the objective structured clinical examination (OSCE).

The "Core" clerkships (i.e. family practice, general internal medicine, general surgery, obstetrics and gynecology and pediatrics) have curricula with many unique features but also have many similarities in the expectations they place on students to develop basic clinical skills. They all demand the ability to solve the clinical problems presented by patients. Most of the challenges and opportunities inherent in outpatient general pediatrics exist in the other clerkships. Consequently, efforts to emphasize development of basic clinical skills and clinical problem solving in the pediatric clerkship will be most successful if similar emphasis is placed in all of the "Core" clerkships. Generalist teaching will be improved if the medical school administration helps develop integrated clerkship experiences. If this cannot be done, clerkship directors could begin by forming "grass roots" linkages between generalist clerkships without the initial participation of the medical school. Formal integration (or informal linkage) of the clerkships would allow more consistent teaching of basic clinical skills and would permit development of a system of longitudinal tracking of clinical competencies, procedural skills and the noncognitive skills that are broadly lumped into the category "professional behaviors and attitudes." Tracking would also allow identification of students who have problems with clinical interactions and would supplement (but not replace) the traditional evaluation of knowledge that currently represents most of student evaluation. Additionally, an evaluation of the clinical skills common to the "Generalist Core" clerkships could serve as a prerequisite for advancement.

The emphasis on generalism has become widespread in medical education. Pediatric organizations that have ongoing initiatives to promote general pediatrics include the Council on Medical Student Education in Pediatrics (COMSEP), the Ambulatory Pediatric Association (APA) and the American Academy of Pediatrics (AAP). The AAP has a particular interest in community-based education for students, discussed elsewhere in this resource manual by Dr. Scheiner. More broadly based activities aimed at the promotion of generalism in the curriculum as a whole come from the Association of American Medical Colleges (AAMC), which has developed an ongoing series of workshops devoted to strategies which enhance the generalist experience in undergraduate medical education. Some state legislatures have placed requirements on state-funded medical schools to produce specified numbers of generalist physicians or face funding cutback. The federal government, through the Bureau of Health Professions, has made the promotion of generalism a focus for program development.

A generalist vision would change the approach to student teaching at the departmental level and in the medical school. The pediatric clerkship would be enhanced by adding the input of general pediatricians and by promoting community-based education. This would ensure that the pediatric clerkship is included among the generalist disciplines in the medical school curriculum, an important consideration given the current state and federal trends to direct funding toward the generalist and away from the specialist. pediatrics would continue to emphasize the unique aspects of health and illness of the growing individual within the context of the family, the community and the society at large. Students would have a greater opportunity to gain an appreciation of how pediatricians work across the entire spectrum of their profession, including clinical activities and nonclinical activities in the university, in the community and in professional and other organizations. The unique contributions of pediatric subspecialists would be emphasized rather than diminished because both the university-based and the community-based pediatrician's consultation with subspecialists would be highlighted, and because the subspecialists would emphasize those aspects of their disciplines that are in the province of general pediatricians. Those Pediatric departments that do not currently incorporate a community-based educational opportunity for students would be strengthened by the addition of community pediatrician input into the teaching program.