Section H

Strategies for Pediatric Subspecialists to
Teach a Generalist Student Curriculum

Susan G. Marshall, M.D.
Ardis L. Olson, M.D.

The education of medical students in this country is undergoing modification as the medical profession attempts to adapt to changes generated by scientific and technologic progress and changing health care financing. The national emphasis to produce more generalists additionally has an impact on the structure and function of most medical school faculties, particularly since such a high proportion of the faculty and many fine teachers are subspecialists. As many medical schools focus energy toward the development of a generalist curriculum, strategies must be developed to aid subspecialists to utilize their considerable teaching expertise at the medical student level, emphasizing more basic and common clinical problems in their field. At the same time, they must continue to be available to students, residents, and physician colleagues for subspecialty consultation.

Today subspecialty divisions predominate in many of our pediatric departments, and gaining support for a "generalist" initiative" will be challenging. Subspecialists who are being asked to support these initiatives while striving to maintain their academic livelihoods in this changing era of health care, may find supporting generalism difficult. However, the reality is that the health care environment is changing and the development of more primary care physicians will be promoted. The subspecialist benefits by a strong foundation of clinical skills in their primary care colleagues, allowing them to collaborate together in clinical care. Towards this end, the subspecialist has an important role providing the crucial knowledge and skills to generalist trainees at all levels so that they will be prepared to practice with the finest foundation we can offer them.

Clearly, pediatric department chairs, clerkship directors, and curriculum committees will play a key role in helping subspecialists maintain a general focus. Several strategies will be paramount:
1) The first is to promote subspeciality and generalist faculty awareness regarding the reorganization of the curriculum and the goals of a generalist curriculum. A solid general pediatric student education is a good beginning for whatever field a student chooses.
2) Next, schools of medicine must provide support for faculty development so that educators can better educate our students about the basic clinical problems.
3) Schools of medicine and departments must provide academic recognition for faculty engaged in the education of students.
4) Subspecialists need to focus the expertise they have developed in their particular discipline to impart essential knowledge to the "undifferentiated medical student".

Broad-based Support
School-wide and departmental support for a generalist curriculum will be crucial in order for such an educational endeavor to flourish. The department chair, clerkship director, and departmental curriculum committee or task force need to be intimately aware of the intricacies of the proposed curriculum and lend it vital support in its initial stages. Meetings with key faculty in subspecialty divisions who are already involved and interested in medical student teaching will aid in implementing the new curriculum and create an awareness surrounding this new "generalist" focus. Division chiefs need to receive information at their meetings with department chairs, and the priority regarding a change in curriculum focus needs to be passed on to all faculty at general departmental as well as divisional faculty meetings.

Faculty Development
At the same time our medical schools must play a proactive role in providing support and resources for faculty development in the realm of education. Department chairs will need to recognize the importance of investing in developing their faculty's teaching skills. Strong faculty teaching skills enhance both the student and resident programs. "Natural" teachers may become discouraged and lend their talents only to clinical or research activities if these skills are not advanced or valued. The concept of continuing medical education is strongly rooted in clinical care, yet often faculty teachers are expected to develop or improve their teaching skills without any input. Departments of medical education and/or outside consultants are of enormous value in providing assistance to faculty as they seek to improve their teaching skills. Faculty development courses should be offered and the chair should expect faculty to attend. More innovative and interactive approaches to teaching and learning can thus be stressed.

Recognition of Teaching Expertise
For the vast majority of subspecialists, academic promotion is based upon excelling in research endeavors. The subspecialist with outstanding teaching talents also needs to be acknowledged, and consideration in the department must be given to developing a "teaching portfolio" as part of the promotion package. However, teaching efforts also need to be recognized in their department by providing subspecialists with positive student comments on an ongoing basis. Most teachers need personal ongoing rewards to feel energized to teach. The clerkship director can give the subspecialist feedback about the results of their student contact (e.g. how their involvement excited a student about pediatrics, the clarity of their teaching session or how they modeled effective communication to the student). Many of the generalist principles are taught well by subspecialists who communicate effectively, work effectively on teams, and think broadly about their patient's needs. The clerkship director can organize these skills and encourage the teaching of these issues.

Teaching Strategies
The faculty subspecialist has an opportunity to be an effective clinical teacher - a teacher for medical students, residents , fellows, physician colleagues, as well as for patients and families. It is critical that the teacher gauge his/her expression of clinical knowledge and expertise to the level of the learner. It may be hard for an expert in a subspecialty field to remember a student's level of knowledge and clinical problem solving if they do not work closely with students. In consideration of the curriculum being addressed here, several observations are offered toward helping the third-year pediatric students become exposed to, experience, and learn basic pediatric principles.

As subspecialists participate in medical student teaching on the wards and clinics, as well as in informal or formal group didactic sessions, they can direct discussions to the broader concepts of the patient's illness with the third-year student. They are especially important at helping students link their basic science knowledge with their clinical experiences. Subspecialists often collaborate in clinical care with the generalists who refer children to them. Subspecialists can utilize their expertise to focus on that part of the physical exam most relevant to their fields. For example, the cardiologist doing bedside teaching rounds can explain all the basic maneuvers necessary to perform an appropriate cardiovascular examination on a child, but also demonstrate more general findings. During group didactic sessions, subspecialists can employ case-based teaching strategies which are practical and relevant to the third-year student. For example, the nephrologist can address hematuria, and proteinuria and how to evaluate these initial signs and symptoms. Pulmonologists can address common problems such as cough and asthma using case-based teaching, rather than a case with extensive diagnostic dilemmas. Gastroenterologists can discuss vomiting and diarrhea and encourage students in developing a method of clinically evaluating common gastrointestinal problems, rather than providing the details of all the disease entities. Hematologist/oncologists can focus on common presentations of anemia and the presentation of childhood leukemia rather than extensive information about their management. Specialists can thus use their extensive knowledge base, clinical experience, and insight to help define those key relevant topics and concepts so critical to medical student learning. It may require discussion between the clerkship director and the subspecialty group to carefully define the core issues to be taught.

Our goal, in encouraging implementation of this new curriculum, is to provide an outstanding educational experience in general pediatrics, as we encourage our students' interest in and recognition of primary care. To achieve success requires mutual respect and balancing the contributions of the subspecialists with those equally important contributions of generalists. Each student will find their unique place in medicine. As pediatrics implements a new and evolving curriculum, devoted teachers, both generalists and subspecialists will be more essential than ever.