Increasing rotation of the pediatric resident in primary care is an option to mitigate the crisis in primary care pediatrics?

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Lona-Reyes, Larissa M. Gómez-Ruiz, Araceli Cordero-Zamora, Sandra I. Cortés-González, Moisés Quiles-Corona, Rene O. Pérez-Ramírez, Herlinda Pinto-Macedo" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Juan C." "apellidos" => "Lona-Reyes" ] 1 => array:2 [ "nombre" => "Larissa M." "apellidos" => "Gómez-Ruiz" ] 2 => array:2 [ "nombre" => "Araceli" "apellidos" => "Cordero-Zamora" ] 3 => array:2 [ "nombre" => "Sandra I." "apellidos" => "Cortés-González" ] 4 => array:2 [ "nombre" => "Moisés" "apellidos" => "Quiles-Corona" ] 5 => array:2 [ "nombre" => "Rene O." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "77" "paginaFinal" => "78" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Ángel Fernández-Cuesta Valcarce, Carmen Villaizán Pérez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Miguel Ángel" "apellidos" => "Fernández-Cuesta Valcarce" "email" => array:1 [ 0 => "miguelangel.fernandezcuesta@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carmen" "apellidos" => "Villaizán Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro de Salud Juan de la Cierva, Getafe, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Salud de Santa Bárbara, Toledo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Incremento de la rotación del residente de pediatría por el centro de salud, ¿una opción para mitigar la crisis de la pediatría de atención primaria?" ] ] "textoCompleto" => "It is clear that we are facing a crisis in paediatric primary care (PC), and there is an important risk of collapse in the short term if urgent measures are not taken. Although in Spain the overall ratio of paediatricians per 100 000 children, including PC paediatricians, hospital-based (HB) paediatricians and paediatrics residents (medical intern-resident [MIR] programme), is above the mean in the European Union, and the report on the predicted supply and demand for medical specialists for 2021–2035<a class="elsevierStyleCrossRef" href="#bib0005">1</a> shows that the overall deficit in paediatric specialists is expected to improve compared to the previous report (probably on account of the decreasing birth rate), this improving trend does not apply to PC paediatrics (PCP).First of all, there is an outstanding deficit in paediatricians in primary care centres, as approximately 25% of existing positions in PCP (about 1300) are vacant or filled by doctors that have not specialised in paediatrics, to which we must add the additional deficits masked by PC paediatricians with caseloads that exceed the recommended maximum of 1000 patients established in the Strategic Plan for Primary and Ambulatory Care of 2019.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>On the other hand, the demographic structure differs significantly between PC and hospital-based care, as PC paediatricians are significantly older compared to HB paediatricians: 52.8% are aged 50 or more years, a percentage that drops to nearly half (27.6%) in the group of paediatricians employed in hospitals. Thus, while 1 in 5 paediatricians in the PC system will reach retirement age in the next 5 years, this will only be the case in 11% of paediatricians employed in hospitals.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>This situation is exacerbated by the preference of paediatricians that have just completed the residency for hospital-based jobs: currently, fewer than 25% of paediatrics residents choose to work in PC when they complete their training.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Although there may be structural factors at play in this preference, such as scheduling and working conditions (changes to which rest with the health care authorities), another essential contributor is the lack of knowledge about PC of paediatrics residents. And this has a lot to do with paediatrics rotations in the primary care setting.Despite the fact that 59% of the paediatrician positions within the national public health system are in PC, the training of paediatrics residents takes place mainly in the hospital setting, so that, fulfilling the requirements of the official curriculum for this speciality, paediatricians-in-training spend only 6% of their residency in the PC setting. Even so, the compulsory 3-month rotation in a primary care centre is not always enforced. This hospital-centred approach to medical education, focused on disease and promoting early subspecialisation, prevents many paediatrics residents from having an integral understanding of paediatric care at the end of their residency.Although the training curriculum approved by the National Commission of Specialities in 1979 specified the need for the paediatrics MIR programme to include training in “community-based paediatrics”, it was in 2006 that a specific PC rotation lasting 3 months in accredited PC centres became mandatory.Since then, the availability of training in PCP has been increasing, with a current total of 453 PC centres and approximately 764 accredited mentors and collaborating faculty offering training in PCP. Given the available resources for education in PCP, the Spanish associations for PC paediatrics (the Asociación Española de Pediatría de Atención Primaria [AEPap] and the Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria [SEPEAP]) have advocated for increasing the duration of PC rotations for paediatrics residents and giving the figure of the PC residency mentor greater prominence. This could increase the teaching capacity for the paediatrics MIR programme (which seems to have capacity in hospital-based paediatrics services), in addition to providing adequate specific training in PC to residents who, in nearly 60% of cases, are going to have careers in PC.This request was reflected in the Strategic Plan for Primary and Ambulatory Care of 2019,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> which includes an action point to propose to the National Committee of the Paediatric Specialty and its Subspecialities the inclusion in the official training curriculum of a mandatory 6-month rotation in PC with the option of extending it to 12 months. This way, the percentage of the time devoted to PC training would increase to 12% of the residency period.Meeting this demand must be necessarily accompanied by adequate training in teaching methodology and the evaluation of collaborating faculty and mentors of paediatrics residents in primary care centres. The current issue of Anales de Pediatría includes an article on the application in PCP of the script concordance test, one of the main methods used in the assessment of clinical reasoning,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and another article on the usefulness of training paediatrics residents on lung ultrasound.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Along the same lines, the Teaching Groups of the AEPap and SEPEAP provide educational materials and hold training courses for tutors and residents. Among them, we ought to highlight the specific courses on PC paediatrics for the residents who are members of either association, the Manual for MIR tutors in PC Paediatrics, edited by the SEPEAP, and several guidelines and documents developed by the Teaching Group of the AEPap (available at the website of the association: <a href="https://aepap.org/grupos/grupo-de-docencia">https://aepap.org/grupos/grupo-de-docencia</a>), including the abridged guide for the paediatrics residency rotation in PC, the outline of the contents covered in the paediatrics residency rotation in PC, the European curriculum for primary care residency training and the European document on the entrustable professional activities (EPAs) in primary care paediatrics (both developed by the European Confederation for Primary Care Paediatricians under the leadership of the Teaching Group of the AEPap) and the contents of the section devoted to preparing for the rotation in PC paediatrics of the Continuum platform, among others. The Teaching Group of the AEPap is also working on designing a flexible training programme for residents who choose to prolong their rotation at the primary care centre.As early as December 2018, the AEP, in its Technical Report on the Situation of Primary Care Paediatrics,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> was already proposing strategies like increasing the duration of the PCP rotation of MIR residents to 6 months, developing a rotation focused on PC practice for year 4 of the residency for residents interested in the field, increasing the presence of PC paediatrics in teaching committees in hospitals and promoting the official recognition and hiring of PC paediatricians as mentors in the paediatric MIR programme. At a time when a draft for a Royal Decree regulating cross-training in the specialities of health sciences and specific training in medical subspecialities<a class="elsevierStyleCrossRef" href="#bib0035">7</a> has been presented to the public for feedback under the public information process in law development, the commitment of the AEP to paediatrics resident training in PC is particularly important.In short, the PC paediatrics profession has amply demonstrated its capacity to provide education. What remains to be done is recognising the value of their contribution to the education of paediatrics residents as an opportunity to improve the system and a guarantee that residents will acquire the knowledge, skills and attitudes necessary to provide high-quality care with a holistic and biopsychosocial approach to children, adolescents and families." 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