Potential Impact on Residents of Having Less NICU Time

The Accreditation Council of Graduate Medical Education (ACGME) recently changed the core pediatric residency requirements to redistribute training between ambulatory care, individualized curricula, and inpatient experiences, while reducing neonatal intensive care unit (NICU) time.1 These changes to the ACGME’s priorities have raised significant concerns within the neonatology community, as reduced NICU exposure may impact the development of some essential pediatric skills, heighten existing workforce imbalances, and decrease preparation for the care of ill infants. Neonatologists’ concerns also include existing imbalances in specialty work hours, heavy clinical full-time equivalent demands, and limited scholarship opportunities.2 Others have proposed solutions that range from establishing independent neonatology training pathways, creation of a neonatology department, or realignment with obstetrics.2 In this article, we advocate for strengthening dialogue and collaboration within the broader pediatric community to achieve our shared goals.Although desirable, regaining lost NICU training time is unlikely. We believe that delivery room and newborn nursery rotations are critical but insufficient to teach the knowledge and skills required to care for infants. As a result, neonatology program directors continue to discuss which critical skills are at risk and strategies to enhance acquisition of these skills within the current ACGME mandates.The NICU is one of the rotations that provides pediatric residents the opportunity to work in a multidisciplinary team in a stressful, high-acuity environment, experience how families and health care professionals cope with end of life (EOL), differentiate between normal variants and disease states, see the evolution of illness over time, and work with families experiencing mental health challenges resulting from their child’s illness and/or prolonged hospitalization. Additionally, NICU rotations with delivery room experience have historically enabled residents to gain experience in the skills necessary to independently stabilize sick infants, which is especially important for those who choose to work in underserved communities. Although some pediatricians may never use the procedural skills experienced in residency, we believe that exposure to procedural acuity and the ethos of responding during crises is as core to every pediatrician as is the understanding of vaccinations or asthma. We hope that the pediatric medical education community will collaborate with us to create innovative strategies to improve residents’ proficiencies that we view as essential (Table 1). Data-driven studies are also needed to understand the impact of the ACGME changes on infant health and resident education, and resident perspectives on the changes.Children younger than 1 year account for a substantial proportion of pediatric care and make up a sizable percentage of the deaths in pediatric hospitals.3 Ill infants can manifest subtle clinical findings that can be mistaken as normal variants, which makes deliberate training important. Newborn nursery and delivery room rotations provide the foundation for learning routine newborn care. However, they do not provide residents the opportunity to learn the differences between “normal variant,” “sick,” and “critically ill” patients; differentiate triage needs; practice initiation of stabilization; and learn procedures required to stabilize sick infants. To promote residents’ education, it will be important to prioritize assigning patients younger than 1 year to residents, teach about neonatal diseases and long-term outcomes, and have resident teams led by neonatologists committed to nurturing learners. Additionally, residents will benefit from engaging in simulations that require them to differentiate disease severity, practice acute stabilization, and communicate within multidisciplinary teams.Most pediatric hospital deaths occur in the NICU and pediatric ICU (PICU), and many have highlighted the importance of EOL and palliative care skills for pediatric residents.1,3 A child’s death can be distressing for experienced health care professionals, and more so for residents who have not yet learned coping skills. EOL experience and education can promote resident empathy and help residents learn how to care for families and children at the EOL. Studies show that pediatric residents have limited exposure to EOL care and that only one-third of pediatric residents perceive that their training prepared them to participate in EOL care.4 Although the ACGME changes reduce residents’ exposure to EOL care in the NICU and PICU, we are still obligated to provide robust opportunities for residents to learn EOL/palliative care skills. We advocate for pediatric residency programs to encourage palliative care rotations, support resident participation in postdeath debriefings, incorporate residents in postdeath family discussions, and develop structured palliative and EOL care curricula. Additionally, education should include simulated patient experiences focused on death, dying, and communicating with families who have lost a child. When possible, residents should interact with former patients’ parents (eg, parent panels) to hear their experiences with health care professionals around the EOL.Every pediatrician should possess the communication skills necessary to care for families experiencing stress and mental health challenges. Families of patients hospitalized in the NICU are at extremely high risk of mental health challenges. NICU rotations have historically provided residents the opportunity to build communication skills. However, resident communication skills are poor, despite current clinical experiences and educational efforts.5 It is imperative that we work on enhancing residents’ competence and confidence in communication via coaching, direct observation with feedback, simulated parent encounters, and facilitated self-reflection.6 We also recommend early NICU rotations to allow residents to directly interact with families undergoing stress and mental health challenges, which will complement much-needed new communication education efforts.In the United States, there is a maldistribution of general and subspecialty pediatricians, and in rural and underserved communities, general pediatricians and family medicine physicians frequently serve as the only resource to triage pediatric patients, initiate acute care, and perform resuscitation and basic stabilization procedures.7 Obstetric and pediatric units have been shuttered in hospitals that are no longer able to provide these services.8 Although it is critical that all pediatricians be able to initiate lifesaving interventions, those going into medically underserved and/or rural areas, where there is little clinical support, are likely to require especially robust skills. However, over the past 2 decades concerns have been raised about pediatric residents’ declining skills, and a 2016 study showed that neonatology program directors rated entering neonatology fellows’ procedural skill competency as poor. Almost 60% of graduated pediatric residents were rated as not competent in mask ventilation and 73% as lacking competence with lumbar puncture.9 Therefore, it is imperative that residents who plan to work in underserved communities develop robust triage, acute care, and procedural skills, because the on-the-job learning curve for new graduates is already inherently steep. These residents should participate in early NICU and delivery room rotations and structured curricula that emphasize skills that may be required in underserved areas. Additionally, yearlong non-ACGME accredited fellowship programs that focus on the delivery room and acute care may be part of the solution.Changes to the ACGME pediatric residency requirements will create opportunities for residents to participate in more ambulatory and individualized curricula. However, the changes also have the potential to further diminish important skills learned in the NICU. Of the many solutions suggested, neonatology program directors advocate for the pediatric education community to be deliberate and innovative in educating residents, so that skills that have historically been gained in the NICU are improved and maintained in other settings.