april 2021

Paediatric training programs across Europe

EXECUTIVE SUMMARY AND AIM OF THE REFLECTIONS

Paediatric training programs across European countries has been and will be subject of intense debate within the Young EAP. Driving forces behind this debate are the wish for high quality child care and thus training programs which lay the ground for the such. One mean to measure the quality of training programs is to analyse the level of satisfaction and identify its levers. This becomes even more important when it comes to creating a common European standard and allowing rising professional mobility.

Young EAP was therefore keen to find out more about the training structures in the European countries, learn about best practice examples and collect ideas that might be included in future training concepts leading to more satisfying, high-quality training structures.

Main findings include the need for clearly organized training structures with a common and flexible trunk, more and allocated teaching and study time, structured onboarding processes, more supervision, frequent feedback sessions on knowledge and skill abilities, fruitful learning environments, support in the area of career development and well-being with the help mentoring, coaching and leadership programs, sound working conditions and a modernized professional working culture.

THE SITUATION

In May 2017 the American Academy of Pediatrics (AAP) published a survey on the satisfaction of paediatric residents with their training, stating that nearly all of them were satisfied with it (1). A first internal survey among Young EAP members showed that European paediatric training programs are organized quite differently and that satisfaction seems to vary across European countries.

Paediatrics is a fascinating and diverse medical field which adds to its attraction. Training in paediatrics needs to address specific aspects uncommon to other medical specialities, such as the broad diversity paediatric patients with special age-related needs, the many topics covered in paediatrics from care of the preterm to the adolescent and relating to a variety of organ systems and related diseases that are covered by many different specialties in adult medicine, the particular social, emotional and ethical aspects associated with their care, including the need to address both the patient and its family, the implications of paediatric care on the long life span that lies ahead, and hence very broad knowledge and skills that need to be acquired by paediatric residents. Therefore, the importance of appropriate training concepts and structures is particularly important in paediatrics.

The various subspecialties within paediatrics have medical particularities related to the patients age group, such as differing diagnostic procedures, social and psychological aspects, consideration of the child’s development, assessment of the level of maturity of a patient, school health and public health. For a paediatric trainee this means for example acquiring broad knowledge and skills, including the ability to interpret findings related to age, communication skills with children and parents, a balanced and well-structured process for problem analysis and solving and for decision-making process, and much more.

Paediatric patients usually come along with parents, and other relatives and close family members, who may have a huge impact on a child that is so young of age and vice versa. This has to be considered in a special way. What does my patients’ treatment or hospital stay mean for his direct surrounding? How do they have to reorganize? What is the family situation at home (patchwork, single parent, siblings, unemployment, (mental) health problems)? For migrating families, traumatic life events and special illnesses may be applicable.

Nowadays, the modernisation necessity of existing training structures is facilitated by increasing options provided through remote learning, new didactical approaches, digitalization and overall greater connectivity. More flexible and adaptive training structures would be beneficial for a society that is so mobile and faces quickly changing living and working environments. The shortage of staff among nurses and physicians, a problem that seems to be prevalent in most European countries, is leading to higher work load, less time for constructive patient interaction and therefore less work satisfaction among health care workers.

We wanted to find out more about positive aspects of training and where there are areas for improvement. Each country has individual approaches relating to its size and specific conditions (geography, economic matters). But since we are working towards a European standard that allows more professional mobility it is only natural that we learn from each other’s experiences, take home what we find useful, apply it to our country and create a common exchange platform that serves all. Having this in mind, we would like to work out suggestions to improve paediatric training structures for trainers as well as teaching centres in order to increase the satisfaction and well-being of paediatric trainees and thus the quality of their work and care provided to their patients.

Methodology

As Batalden and Davidoff stated ‘Although all improvement involves change, not all changes are improvement.’ (2). We started our journey of internal exchange on training structures in mid 2018 with a shared excel sheet that was filled out by 18 member countries (Austria, Belgium (Flanders), Croatia, France, Germany, Hungary, Ireland, Italy, Latvia, Lithuania, Malta, Montenegro, Netherlands, Norway, Slovenia, Spain, Sweden, UK) where information on training structures (number of years of training, accreditation processes, assessment structure, didactical approaches used, functionality of supervision, teaching etc.) were compiled. A summary of information on national training structures can be found in the form of country profiles on our website soon. This survey was complemented by telephone interviews among Young EAP national representatives from 10 European member countries in July 2020, who met online in groups of three or four to give an overview on their paediatric training programs and exchange on up- and downsides. Participating national representatives were randomly combined and allocated and are from the following countries: 1st group: Finland, Portugal, Slovenia, UK, 2nd group: Malta, Sweden, Ukraine, 3rd group: Belarus, Germany, Netherlands. Before the meeting, all participants received a questionnaire designed to make people think about different aspects of training programs and the working conditions that come along with it. It also provided the moderator of the session with a guideline for a more productive discussion (the questionnaire can be opened under the following link). Further questions and discussion around the questionnaire were included.

ASPECTS OF TRAINING ELEMENTS WHICH WE DISCUSSED

Training structures

Training structures should adapt to the level of competency. When you first start to work as a doctor you lack experience and your clinical view and intuition have to be trained. This means closer observation and supervision making sure there is transparency on your skill set, structured professional feedback sessions in the beginning (ideally in an outside of the ward setting) with fewer sessions towards the end of your training. We believe that it would be desirable to have a common trunk with fixed rotations, followed by a more flexible trunk that allows mobility and time for rotations based on individual interests and professional growth.

Rotations

Not all countries offer compulsory rotations throughout the training. Most of us agreed that rotations in Neonatology, Infectious Diseases and Paediatric Intensive Care are most important for everyone working in paediatrics followed by Oncology and primary care paediatrics. One rather specific rotation that many expressed their wish for is a rotation in radiology and even more specific in ultrasound skills since it is frequently needed and often a useful diagnostic procedure in paediatrics. In order to raise awareness for paediatrics, and exchange more with relevant political, public health or non-governmental institutions it could be an innovative approach to allow paediatrics related rotations in these areas. This could lead to more interconnectedness among health care actors nationally and internationally.

Allocated study time and assessment

All of us would wish for more allocated study and teaching time. Often there is too much paper work that prevents one from attending valuable teaching units if these even exist. Thus, there is a clear need for dedicated time slots for teaching and studying, integrated in the individual schedule. The latter is a key pre-requisite (conditio sine qua non) to ensure focus and adherence to a plan leading to increased satisfaction and quality.

Assessment is enriching for personal and professional development. In most countries there is some kind of summative assessment (assessment that evaluates student learning i.e. an assessment at the end of training, or at a fixed point in training), whereas formative assessment (assessment that monitors student learning i.e. happening throughout the training informally) is rather dependent on the quality of your supervisor. Ideally there should be repetitive summative assessment during each rotation in combination with an assessment at the end of the training. Formative assessment should be part of a functioning high-quality teaching system and should therefore take place regularly throughout training.

Supervision, feedback and onboarding

Too many paediatric residents feel they receive insufficient supervision. Many perceive supervision as too personality-dependent and that it varies according to the relationship between the resident and the supervisor. Supervision not only accounts for handling clinical cases but also for accurate documentation and the layout of the physician’s letter which is also an act of respect to the colleague who does the further treatment. Regular structured feedback would be desirable for most residents and provides valuable input for personal growth and professional development.

In this context we would also like to highlight the need for specific training for supervisors and a job plan that allows enough space for supervision, structured feedback, collective learning and a supportive learning environment.

There are methods and tools by which supervision can be facilitated that should be further evaluated. The Dutch training program for example works with Entrusted professional activities (EPA) that make competency-based decisions on the level of supervision required by trainees (3). This is a useful tool, which could easily be adopted by other European member countries.

Especially when one is new to a working unit a well-structured caring onboarding process (this can also include additional ‘homework’) would help to get familiar with the most common cases, revise relevant medications and diagnostic procedures as well as social and emotional aspects. This might take up some extra time but is rewarded by a motivated and rapidly involved colleague.

Learning environment and adverse events

The learning environment has to be free of negative emotions if it is to be fruitful. Questions should always be allowed (around the clock) and answered in a respectful manner. Insecurities, knowledge and skill deficits can and have to be addressed in structured neutral feedback sessions which will be of great value for the trainee who is then, in collaboration with the supervisor, responsible to improve such skills and re-evaluate them later on. This is the only mean by which the learning curve can run more steeply in a sustainable manner. Denial, neglect or even mobbing is toxic in clinical working environments and puts patients at risk. This explicitly accounts for everyone working in the clinical arena. Adverse incidents should be reported and discussed individually and, in the team, if needed with the support of a mediator. Patient safety is of great importance thus it has to be our aim to avoid not to learn from a mistake that has been made. This again underlines the value of regular neutral feedback on personal and professional traits, a vivid team culture and respect for the individual.

Working conditions, workforce and modern working models

Unfortunately, an under-resourced workforce seems to be present in more or less all European countries. This is a major problem that affects nurses and physicians and that has to be addressed. Not only does it diminish the quality of care provided, but also limits time for teaching and studying enormously, thus deteriorating working conditions. We should aim for well-organized working environments providing room for full concentration, enough time to reflect thoroughly and exchange with your supervisor, do precise documentation and at the same time allows you to be kind and empathetic to your patient instead of inducing more stress. It is crucial to get the chance of running ward rounds without interruption, without at the same time having to react to the beeper for the emergency unit and a patient load that make it impossible to overview each case as appropriate. The introduction of new technologies will help to better organize working environments in the future.

In some countries, residents are facing limited employment contracts on a regular basis creating insecurity, demotivation and uncertainty with long-term plans for young families. Where possible, part time contracts and working models should be further developed and implemented, since high numbers of future paediatricians aim for parental leave, in order to spend more time with their children and support their partner.

Mentoring, Coaching and leadership trainings

In many European countries there is neither a mentoring or coaching system nor a leadership program implemented in paediatric training. This would be highly recommended and desired by paediatric residents. As Michael West evaluated in ‘Caring for doctors – Caring for patients’ a high-quality medical care is based on a healthy workforce (4). This includes reasonable working and training conditions that are adapted to the needs of a modern society. Functioning mentoring, coaching and leadership programs are one mean by which the well-being of the workforce can be supported and how grievances can be more easily identified and addressed. A study by the Challenge and Support Research Network in the Netherlands showed that ‘personal resources safeguard the work engagement and lessen the risk of burnout of residents and specialists. Both residents and specialists benefit from psychological capital to maintain optimal functioning.’ (5).

Mentors or coaches can be members of their own training facility or from an external facility making them more objective discussion partners depending on the personal preference. In some countries that provide a mentoring system, the quality of interaction is too dependent on personality-personality interaction; this may lead to a lack of necessary and helpful interaction. In such cases an online matching profile system with an underlying algorithm could be helpful. Such an example is especially useful for large-scale facilities. A successful example has been developed and established at the medical faculty of the University Munich, Germany in 2008 where a platform was created enabling volunteer prospective mentors and mentees to create an online matching profile that includes scaled and multiple-choice items focusing on areas of interest and aspirations for the future. Based on the collected information the ten most suitable mentors are then linked according to an automated matching algorithm from which the mentee can then ultimately choose (6).

A good example for a successful coaching system has been set up in the Netherlands under the name of ‘Challenge and support’ (https://challengesupport.nu) that helps medical professionals define and achieve their career goals, identify personal resources relevant for motivation and personal well-being, diminishes stress and burn-out symptoms and improves finding resources for recovery and the establishment of the right equilibrium for the individual work-life-balance (7).

Additionally, it was highlighted by several interview partners that leadership trainings would be of help not only for residents but also for their supervisors and senior physicians.

Professional culture

The saying by Peter Drucker ‚Culture eats strategy for breakfast‘ is applicable to all kinds of working environments. The best strategy, in this case training structure, will not pay off as planned if there is no vivid professional culture shared among the paediatric workforce. Some aspects of a professional culture that has to be defined could be (this list is not intended to be complete):

• Patient first
• Positive impact
• Investment in the next generation
• Acknowledging the social and psychological complexity of a paediatric patient
• Responsibility
• Trustful partnerships
• Unlock potential
• Respect for the individual
• Patient safety
• Positive conception of man

We profoundly believe in the underlying assumption that all members of the medical workforce work to the best of their knowledge and belief on a daily basis. It is always challenging to turn theory into practice, but everyone should get the opportunity to live up to their full potential, receive individual support, second chances, grow as a physician and support others. This conception helps to get to the root of why training might not always work as it should and that we are all responsible to find better solutions.

LEARNINGS AND WHAT WE WISH FOR IN THE FUTURE

All participating representatives enjoyed the in-depth insight that they gained by the fruitful exchange among the group of European paediatric residents. The thorough discussions helped us to learn more about best practice examples and made us realize that we share common wishes for the future. Interconnectedness in the field of paediatric training structures should be expanded and organized more formally on a long-term basis for the improvement of quality of care provided to children across Europe. This should also include the possibility of visiting teaching structures in other European countries in order to learn more about the different teaching settings and facilitate cooperation.

Future wishes for paediatric training structures therefore include: 

• Rethinking basic training structures allowing a common trunk with fixed rotations and a flexible trunk with flexible rotations based on the individual interests
• Allocated non-negotiable teaching and study time
• More supervision that is based less on personal traits or preferences but rather is objective. Supervision also includes to protect the right of further education for trainers and liberty for self-chosen topics.
• More structured assessment with summative and formative components and which provides individual feedback on progress and development support
• Mentoring and coaching that is more individualized, which could be achieved via a structured matching process. More leadership trainings for residents but also for supervisors and superiors would be desirable, highlighting the importance of ‘train the trainer’

More investment in the workforce with a responsible personnel politics, reliable contracts and modern part-time working models

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REFERENCES

1. https://www.aappublications.org/news/2017/05/04/Research050417
2. Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare?. Qual Saf Health Care. 2007;16(1):2-3. doi:10.1136/qshc.2006.022046
3. Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5(1):157-158. doi:10.4300/JGME-D-12-00380.1
4. https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf
5. Solms L, van Vianen AEM, Theeboom T, et al. Keep the fire burning: a survey study on the role of personal resources for work engagement and burnout in medical residents and specialists in the Netherlands. BMJ Open 2019;9:e031053. doi:10.1136/ bmjopen-2019-031053
6. von der Borch P, Dimitriadis K, Störmann S, Meinel FG, Moder S, Reincke M, Tekian A, Fischer MR. A Novel Large-scale Mentoring Program for Medical Students based on a Quantitative and Qualitative Needs Analysis. GMS Z Med Ausbild. 2011;28(2):Doc26. DOI: 10.3205/zma000738, URN: urn:nbn:de:0183-zma0007385
7. https://challengesupport.nu/waarom-coaching

About the authors:

Lena de Maizière represents the German pediatric trainees within Young EAP. She is a 5th year paediatric resident.

Sian Copley represents UK paediatric trainees within Young EAP, and is the Young EAP Representative for Advocacy. She is a 6th year resident from the UK working in the North East of England.

Miguel Vieira Martins is a 5th-year trainee in Pediatrics and Neonatal Care at Centro Hospitalar Universitário Cova da Beira, Covilha, Portugal. Originally having graduated from the Medical School of the University of Lisbon in 2011, Miguel has pursued a career in Child Health with a keen interest in Oncology/Hematology.

Reviewed by:

Rob Ross Russell is the Director of Medical Studies at Peterhouse, University of Cambrigde. He is also the current Chair of the European Board of Paediatrics. Rob works at Addenbrooke’s Hospital in Cambridge, where he has been a consultant in Paediatric Intensive Care and Paediatric Respiratory Medicine.

Karoly Illy is the Chair of the Secondary Care Council of the European Academy of Paediatrics and president of the Dutch Paediatric Society. He is a paediatrician at the Ziekenhuis Rivierenland Tiel in the Netherlands.

Berthold Koletzko is a Prof. of Paediatrics at the Ludwig-Maximilians-University of Munich (LMU), a paediatrician at the Children’s Hospital and Children clinic of the Dr. von Hauner Children’s Hospital, and a EAP member.