ORLANDO — Pediatricians become part of the social capital of their communities, Stanley Fisch, M.D., said at a meeting sponsored by the American Academy of Pediatrics.
The concept of “community pediatrics” means a synthesis of clinical practice and public health principles aimed at providing care for each child and promoting the health of all children within family, school, and community settings, said Dr. Fisch of the University of Texas, San Antonio.
Community pediatrics as a discipline has the same elements as other specialties, with knowledge, skills, and attitudes that can be learned and developed, and Dr. Fisch offers several strategies for pediatricians who want to take residents into their practices.
“Medical education has changed rather dramatically in the past several years,” Dr. Fisch said.
There has been a shift from emphasis on inputs to emphasis on outcomes, where “core competencies” are the benchmarks and objectives of achievement. Testing of knowledge and skills has given way to the development and assessment of competencies, he said.
That said, community pediatrics as a discipline can be taught, and taught very well.
For those interested in teaching the next generation, Dr. Fisch offers a 12-step program as a guide to initiating and completing a successful experience with students and medical residents.
Proper preparation makes all the difference. “Sometimes your partners might not want to get involved with teaching, and that's OK,” Dr. Fisch said. But that puts the pressure on you to be organized and to not disrupt the normal routine of your office.
The 12-step program is outlined below:
1. Plan ahead. Where will the learner park his or her car, keep personal items, and have desk or computer space? Don't forget to inform the office staff and introduce them to the learner.
2. Self-orientation. Ask the learner to state three goals for his or her experience in community pediatrics.
3. Orient yourself to the learner. Find out about your resident's background and interests.
4. Site orientation. Have the office manager or a nurse orient the learner to the office environment.
5. Precepting preparation. Look to the next day's schedule and select patients whom the learner can see and topics they can review.
In addition, let them spend some time on the phone answering questions alongside the nurse or whoever answers the phones during the day.
One of the core competencies is systems-based practice, which means that when the doctor needs to attend a credentialing meeting, for example, it is an opportunity for the learner to tag along to see how a practice affects the profession as a whole.
6. Chart review. Of course, finding the “teachable moments” throughout a busy day remains a challenge. Take opportunities as they come.
For example, allow the learner to review a patient's chart, and point out examples of complete vs. poor documentation, as appropriate.
7. Commitment to a plan. Encourage learners to commit to an opinion about a diagnosis, treatment suggestion, or lab result. This opens the door for feedback about clinical skills.
8. Elaborating on the plan. When time permits, ask the learners how they arrived at the conclusions they offered, recognizing that both the process and the outcome are important.
9. Soliciting feedback. Giving feedback can be one of the most difficult aspects of teaching. Asking learners to offer their own assessment of how things are going opens a window for feedback.
This method often helps learners clarify how they are doing and where they should focus more attention.
10. Timing feedback. Setting aside a specific time and place for feedback may make this process easier for the teacher and more helpful for the learner.
Dr. Fisch offers a “recipe” for an effective “feedback sandwich.”
In its simplest form, good feedback reinforces what the learner did right, corrects mistakes, and offers suggestions for improvement. More specifically, effective feedback is:
▸ Detailed, rather than general.
▸ Focused on behavior rather than on personality.
▸ Descriptive, rather than evaluative.
▸ Timely.
▸ Private, if possible.
▸ Prefaced with positive comment.
▸ Focused on suggestions for his or her improvement.
11. Generalizing learning. Encourage learners to improve clinical thinking by asking effective questions, such as “What do you think causes X?” and “How are X and Y similar?”
12. Reflection. Take a few moments at the end of the day and encourage learners to choose some themes or topics to explore on their own.
Community pediatrics begins with knowledge of the community.
To that end, Dr. Fisch recommends a “windshield survey” to provide residents with a sense of the community's social capital, resources, and unique characteristics, such as safety issues, types of schools, and public transportation.