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Tuesday, September 6, 2011

On the Job Training for Doctors?

A recent report showed a large discrepancy between what pediatricians believe they should do to advise parents and kids on sleep, and what they were actually trained to do, which begs the question: What are pediatricians NOT trained to do but must do as a routine part of their job?

What is this discrepancy?  The Journal of Pediatrics published a report that only 18% of pediatricians reported having formal training in sleep disorders, but 96% felt it was their job to treat them.  Their conclusion is that training programs should provide sleep education.

While on the surface this sounds like a great idea, reflecting back on my training and early years in practice, residency would have to be extended by many years to teach all that I need to know at my job. Teaching sleep hygiene (or not teaching it) is just the tip of the iceberg. Not to mention that there is new information all the time about how to do things better, so the learning should really never end.

I learned about car seats after my son was born during the end of my 3rd year of residency.  
How did I make it 3 years without learning about car seats???  I would simply mention to parents to be sure to use one.  If they had specific questions about if the baby was properly in the seat, I referred them to a car seat expert.  (We refer to a lot of experts in residency.)
We took my son home from the hospital on an icy February day in a warm jacket  buckled into the car seat.  When we got home and I went to unlatch the buckle I realized it had never clicked. The jacket was too bulky!!!  We went to a car seat check a couple weeks later and his car seat wasn't even tight enough ~ this is before the LATCH system helped secure the seat.  My own baby had been unsafe.  How awful is that after nearly 3 years of pediatric residency?  Of course now, 12 years later, many car seat rules/recommendations have changed.  Gotta keep learning!

I had a little formal education about breastfeeding, but it was mostly the technical aspects of how milk is produced, not how to help a mother/baby be successful with breastfeeding.  That I learned when struggling to breastfeed my first baby, and along the way with other moms and their various problems.  My second came along and breastfeeding went great, but she wouldn't take a bottle.  Boy, did I learn a lot from my own kids with two very different feeding problems.

I don't remember a single lecture on nutrition, though I'm sure we had them.  Not much on exercise that I recall.  These would have been considered "easy" topics and as a resident we were more focused on studying acid base disorders and intricate diseases because that would be what we would be tested on.  I wish I learned more about nutrition and exercise psychology because of the current level of obesity, but it is a relatively new problem in pediatrics -- one even the specialists aren't sure how to manage. 

It is estimated that 40% of primary care visits involve behavior problems, yet I only had a single one month rotation on psychiatry.  I am still learning new tricks 12+ years into practice.  Many of my experiences as a parent color what I have learned in this arena.  I also have the privileged position to learn from the families I see at work.  All of this information I use to counsel families about these issues.  I could never have learned this in a lecture, or even in a clinic with a preceptor for a one month rotation.

Simple things, like what to do with a baby who has a nose filled with mucus, were not discussed in lectures because there were more advanced things to learn, like how to manage a child on a ventilator.  I don't ever manage ventilator's now, but I had to learn how in residency.  Why learn that?  Because it teaches doctors to think.  

We need to learn the basics in school about how the body works.  The psychology, pharmacology, physiology, and all the other -ologies.  

Residency teaches us how to apply these things to the human person.  Treating the sickest of the sick in the hospital setting teaches us to recognize sick and become independent learners.  


Starting up in practice teaches us more about common illnesses and concerns. We sharpen the skills of disease management and normal growth and development with all of its variances from following the same kids over years.  We must incorporate everything we know from books, lectures, clinical experiences, personal experiences, and more into caring for our patients with the most current evidence based and practical methods available.
And that keeps changing, 
          keeping pediatricians life long learners!