So you've signed on for a future in pediatrics. Good plan! Your next step is to secure training that fits your needs and temperament.
As medical students take core rotations in the third year of medical school, they begin to work with their advisors and pediatric clerkship directors to further refine career goals and investigate residency opportunities. Some will be drawn to academic medicine at a medical school or teaching hospital that will accommodate a subspecialty concentration, teaching, and research. Others will prefer an office- or hospital-based clinical practice. Summer externships, volunteering at a children's hospital, physician shadowing, and helping with projects within pediatric departments are ways to further explore initial inclinations.
Applying for Residency: Weighing the Options
The number and variety of residency programs complicate the daunting business of deciding where to apply. It is important to give some thought to personal preferences and priorities before attempting to assess programs. Any accredited pediatric training program can lead to fellowship training in subspecialty pediatrics or a career in general pediatrics, which underscores the importance of choosing a program based on the best personal fit.
This information below describes "regular" (or categorical) residency programs, which offer 3 years of training in pediatrics. Combined training programs provide training in pediatrics and another specialty, such as internal medicine.
Number of Trainees
Programs may range from 4 to more than 50 residents per year. Smaller programs often offer more individualized attention and perhaps closer relationships with more faculty members. Larger programs often offer more options for clinical training venues, such as continuity and subspecialty clinics, electives, and hospitals. They also tend to have a larger body of faculty with more diverse clinical specialties.
University-Affiliated vs. Stand-Alone Programs
Most residency programs are affiliated with medical schools. In general, university-affiliated programs may offer an advantage in applying for fellowship training, especially for the more competitive fellowship programs. The few existing programs that are not directly associated with medical schools may be excellent choices for students due to location, desired features, innovative rotations, or even direct training in managed care.
Children's Hospital or General Hospital
Training in a stand-alone children's hospital has advantages and disadvantages, as does training in a general hospital with pediatric areas or floors. Children's hospitals tend to provide more comprehensive care for children as they are completely equipped for pediatric medicine. Procedures and ancillary services are developed with pediatric care as the centerpiece (child and family friendly), which affects laboratory and radiology services as well as informatics and chart note templates. Also, children's hospitals tend to have a broader, systems-based understanding of the care of children and their families because they coordinate multiple medical services with a common focus and expertise in the care of pediatric patients.
General hospitals with pediatric units also offer unique advantages. In general hospitals, residents often have more contact with residents from other specialties. A multidisciplinary resident staff in a general hospital facilitates broader cross specialty resident events, such as a general medicine review for all residents preparing for Step 3 of the USMLE, where internal medicine residents can learn from pediatric residents and vice versa. Some pediatric areas within general hospitals are also quite robust and developed, thereby minimizing many of the differences between these care settings and those that are found in stand-alone children's hospitals.
An Institution With or Without Fellowship Programs?
Opportunities to work with fellows during residency are excellent ways to evaluate subspecialty options. Programs with many fellows are also programs that have more teachers for each specialty area because both the faculty and fellows serve as sources of your education. That said, institutions without fellowship programs often allow more direct contact between residents and subspecialty attendings, which can translate to more autonomy for resident decision-making, compared to fellow decision-making, in the care of the patients.
Many residents develop ties to the communities/hospitals in which they do residency and would prefer to complete their fellowships in the same institution. If the training institution has a desirable fellowship program, graduating residents, who are well known to the faculty, may have an advantage in the selection process.
Certain residency programs have been approved to identify one or more tracks that allow the resident to explore more options relevant to what they wish to do after residency training. Common tracks focus on primary care, community pediatrics, research, international child health, and public health.
The Pediatric Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) has requirements for most accredited programs. For example, all programs must offer a block of developmental pediatrics and a block of adolescent medicine rotations. While about two-thirds of resident rotations are stipulated by ACGME, a program's choices for the remaining one-third will vary according to local staffing (subspecialty rotations) and the orientation of the program towards accomplishing local goals. When considering programs, review the options for elective rotations and those for being part of a track. Does the program use this time to maximize your learning opportunities?
A primary care track often offers extra clinical preceptorship months for residents to explore the various settings for general pediatrics – private practice, managed care, or community specialized rotations to enhance communication skills. These might include opportunities in child psychiatry or working with parents who are in treatment for addiction. International tracks offer a gateway to an important and expanding field of global health with opportunities to work in a clinical site abroad. Community or advocacy-based tracks offer continuity clinics and preceptorships in community health centers. They also often require that students design, implement, and evaluate an advocacy related project or a research project focused on community health. Often, students with a combined interest in public health and pediatrics enter tracks such as this if a separate public health track is not offered. Pediatricians are often leaders in public health in the United States (in the last 30 years alone, 3 pediatricians - Joycelyn Elders, MD, Julius Richmond, MD, and Antonia Novella, MD - have served as US Surgeon Generals!).
Research tracks appeal to candidates with a combined MD/ PhD, as well as those with an interest in bench, clinical, or other research. They also provide useful experience for those planning to pursue subspecialty fellowships, which have research requirements. The American Board of Pediatrics (ABP) offers 2 special routes for pediatrician scientists who may be qualified to devote time to research during training. The Integrated Research Pathway permits 11 months of research during 3 years of pediatric residency training prior to entering a 3-year pediatric subspecialty fellowship. The Accelerated Research Pathway enables selected candidates to enter fellowship after two years of general pediatric residency, completing that additional year in research time during fellowship. More information on these opportunities is available from the ABP.
The Big Picture
Regardless of the particular program, pediatric residency training is designed to confer the knowledge, skills, and attitudes required for comprehensive, longitudinal, and family-centered health care. Pediatric residents learn to consider behavioral, psychosocial, environmental, and family-unit correlates of disease. They learn to care for children who are chronically ill and manage acute events as well as promote wellness and prevention. Because pediatric residents work with so many other members of the health care team in the management of children, they learn to be collaborative in their approach to care. It is this common devotion to the care and well-being of children that makes pediatricians among the most professionally satisfied of all physicians.
It is important to remember that residency is a time for exploration. Choosing a program based on certain tracks does not restrict exploration of other types of pediatric practice. Any accredited residency program can lead to fellowship training. Many residents enter general pediatrics tracks and then discover an interest in a subspecialty. Also, every residency program allows elective months, when residents can explore subspecialty or other rotations.
The relative importance that an applicant gives to training program features and benefits will reflect his or her individual preferences and priorities. (For example, when an applicant must stay in a given location due to spouse/partner commitments, geography will be critical.) Many residency candidates are relatively unclear about what is most important to them until they visit programs during the interview process. This is normal. It is also one of many situations in which a clinical advisor can offer invaluable insight.
Combined Training Programs
Several combined programs are available to medical students interested in training to be board certified in both pediatrics and an adult specialty or pediatric subspecialty. Graduates of combined programs are able to sit for 2 (or in one case, 3) examinations.
The primary advantage to completing a combined residency program is fewer years of training; a combined program can be completed in one or two fewer years than individual residencies and fellowships taken in sequence. All combined programs truly combine the general pediatric training with training in another area, completing rotations in the respective components of the training program within each year of residency.
The American Board of Pediatrics (ABP) has cooperative arrangements with several other specialty boards for combined training. Students who successfully complete these programs and pass certification examinations administered by all boards involved are said to be "double boarded" (or in some cases "triple boarded"). Specifics vary and can be pursued with the ABP and the other individual specialty boards, whose contact information is linked to the ABP Web site. The ABP approved combined training programs include:
- Internal medicine-pediatrics (med-peds) (4 years)
- Pediatrics/anesthesiology (5 years)
- Pediatrics/emergency medicine (5 years)
- Pediatrics/medical genetics (4 years)
- Pediatrics/physical medicine and rehabilitation (5 years)
- Pediatrics-psychiatry/child and adolescent psychiatry (5 years)
The most established of these programs combines a pediatric residency and an internal medicine residency for a 4-year medicine-pediatrics (med-peds) training program. Practicing med-peds physicians see patients in clinics and in hospitals. There are approximately 79 such programs in the United States. Residents in this combined program split their time between adults and children, completing 2 years of rotations in each specialty. Some programs have combined ward services and continuity clinics that allow residents to care for both adults and children on the same day, while other programs split the residents' time between internal medicine rotations and pediatrics rotations. Graduates are able to take both the internal medicine and pediatrics certifying exams.
The pediatrics and medical genetics residency is a 4-year program that combines two years of general pediatrics and two years of genetics training. (The alternative for those interested in both disciplines is a 3-year fellowship in medical genetics following pediatric residency.) As of this writing, there are 18 such programs in the United States that qualify graduates to sit for both the pediatrics and medical genetics certifying examinations.
Graduates of a 5-year combined program in pediatrics/ psychiatry/child psychiatry are eligible to test for board certification in all 3 disciplines. Nine programs currently offer this "triple board" residency.
Three programs offer a combined residency in pediatrics and physical medicine and rehabilitation (PM&R). Completion of this 5-year program allows graduates to sit for both the pediatrics and PM&R board examinations. Individuals wanting subspecialty certification in pediatric PM&R will need to complete an extra year of fellowship (and take a third exam) in addition to the combined program. For those who do not elect a combined program, pediatric PM&R training is a 3-year fellowship following either a pediatric or a PM&R residency.
A combined residency in pediatrics and emergency medicine is available through four programs in the United States. Five years' training qualifies graduates to sit for both the pediatrics and the emergency medicine boards. Individuals wishing further subspecialty certification in pediatric emergency medicine require further training. For those who do not choose a combined program, pediatric emergency medicine training involves a 3-year fellowship after pediatric residency or 2- to 3-year fellowship after emergency medicine residency.
In 2010, the American Board of Pediatrics and the American Board of Anesthesiology announced a combined program in pediatrics and anesthesiology. This five-year training is available at seven programs in the United States and can lead to certification in both fields.
Although medical graduates interested in child neurology and neurodevelopmental disorders have an option that condenses training by 1 year, this is not a "combined program" in the same sense as those discussed above. Pediatric neurology programs admit residents who have completed 2 years of a pediatrics residency; after 3 years in the neurology residency, graduates are able to sit for both the pediatrics and neurology boards. The 2 years of pediatrics residency must be designed to include all of the core rotations required by the American Board of Pediatrics; residents cannot simply start a pediatrics residency and leave after 2 years to join a neurology residency. Passing the neurology boards results in certification in neurology with "special qualifications in child neurology." An alternative path is to take 2 years of a pediatric residency followed by 4 years in a program in neurodevelopmental disabilities. As they are not truly "combined" programs, application is a bit different. Some residency programs will coordinate the first 2 years of pediatrics with the last 3 or 4 years of neurology at the same institution, but others do not.
Combined programs are longer than a 3-year general pediatrics residency but may be a good choice for students interested in a specific subspecialty pediatric practice or interested in both adult and pediatric medicine. As new programs are added annually, and some centers close their programs, it is important to look up the most current information before applying. The Accreditation Council for Graduate Medical Education website has the most current listing of all programs and sites.