Developing models for pediatric residency training in managed care settings.

The preparation of pediatric residents to function optimally in managed care environments challenges educators to create a new set of educational objectives and competencies and to incorporate these into curricula that are already full. Many of the skills needed to practice managed care are those that have been required for the practice of pediatrics in any setting. Nevertheless, the emergence of managed care requires the identification of new knowledge to be acquired and new skills and attitudes to be incorporated into daily practice. These competencies can be identified most thoroughly through collaboration among physicians, educators, and leaders of managed care organizations. This joint effort should also serve to establish a foundation on which collaborative, mutually beneficial learning environments can be created. The development of curricula that provide the opportunities needed to attain managed care proficiencies requires an individualized approach for each program that takes into account the degree of managed care penetration in each training environment. Programs in which a managed care approach to patient care predominates will be able to promote most easily their trainees' incorporation of these principles into routine practice. Those with less regular exposure will be forced either to promote managed care principles in an environment in which they may not be accepted or practiced, or to join in partnership with managed care organizations (MCOs) to train residents. Regardless of the setting, evaluation methodologies must be developed to ensure that each of the core competencies has been learned, can be applied to clinical situations, and is retained throughout the training period. These efforts require the development of faculty who understand and can model a managed care approach to patient management. The ongoing evolution of managed care systems encourages the development of new, creative strategies to train faculty, who may find themselves learning about this emerging environment at the same time as are their trainees.

Evaluation of clinical competence: the gap between expectation and performance.

OBJECTIVE: To evaluate a 3-year experience with the Objective Structured Clinical Examinations (OSCEs) and to compare faculty expectations with resident performance. DESIGN: Descriptive analysis of measures of resident performance. SETTING: Community-based pediatric residency program in Michigan. PARTICIPANTS: One hundred twenty-six pediatric residents at all levels of training. METHODS: The three examinations consisted of 36 to 42 5-minute stations, testing skills in physical examination, history, counseling, telephone management, and test interpretation. A committee of faculty and chief residents predetermined minimum pass levels for each resident level. Results were compared with other indices of resident performance. RESULTS: There was evidence for content, construct, and concurrent validity, as well as a high degree of reliability. However, 40% to 96% of residents scored below the minimum pass levels for their levels. In each examination, third-year residents had the highest failure rates, yet they scored well on the American Board of Pediatrics in-training examination and on their monthly clinical evaluations. Furthermore, for residents at all levels, the scores reflecting application of data were significantly lower than those assessing data gathering. CONCLUSIONS: The gaps between expectations and performance, and between data gathering and application, have important implications for institutional educational philosophy, suggesting a shift toward more clinically oriented and learner-directed strategies in the design of instructional and evaluation methods.

A dicentric recombinant 9 derived from a paracentric inversion: phenotype, cytogenetics, and molecular analysis of centromeres.

A 4-year-old girl with multiple malformations and severe developmental delay has been shown to have a karyotype of 46,XX-9,+rec(9),dup p,inv(9) (q22.1q34.3)mat, with duplication 9pter-q22.1 and deficiency 9q34.3-qter. This case confirms that a stable recombinant chromosome can result from a paracentric inversion. The recombinant was derived by two crossovers, one within the inversion loop and a second outside the inversion loop, between 9q21 and the beginning of the meiotic inversion at 9q22.1. In 87 cells the rec(9) had one Cd-positive primary constriction. In 13 cells the rec(9) had two primary constrictions; in 12 of these cells there was one Cd-positive centromere, and in one of these cells both primary constrictions were Cd-positive. Nuclear projections were observed in 10% of fibroblast interphase cells harvested in situ, suggesting that there was some spindle-fiber activity of the "latent" centromere. In situ hybridization with a centromere-specific probe (p82H) and a satellite III probe (L6) revealed no differences between the two C-band regions of the rec(9) and the normal 9 or inverted 9 chromosomes.