We recommend a core team, extended team and extended community team. One consideration is the family's goals for the child and the other is childhood morbidity and epidemiology. There is tension between those two. The latter is “evidence-based.” Our team could consist of any number of different providers like physicians, mental health providers, nutritionists, social workers, etc.

Key concepts in education were co-training, or people working together. Leadership and collaboration are included. Interdisciplinary training is included. In offices there is no room for “teams” so proper settings should be created in the physical space.

We felt it is important to have patient-based learning vs. problem-based learning. The child has the disease and not vice versa.

We talked about faculty models. Residents behave like their attendings. Example is the only way to lead. For residents to become good team members their leaders must be good ones.

Our question to take forward is the tension one. A glaring example is a malignancy where the parents want to try alternative treatments but we know proven ones. How do we reconcile that? People don't always know what they want. The practice should not be like McDonalds, “what do parents want from the menu?”

We talk about working together, but then each specialist changes the chronically ill patient's medication. So then we say collaboration is not important. The attending “du jour” makes the decisions regardless of who is involved or prior decisions. Our pattern of work and dealing with patients is what it is today. We have to consider it won't be like it was 40 years ago. We have to achieve continuity in a realistic setting.

We ought to elevate the decision to the top of the accountability chain for the family. That will cause us to work together.

Faculty development should include teamwork and communication skills. Teamwork and continuity is where things work best. We should create role models. One of the spin offs of our project is reengineering the in-and-out patient teams. We have lost sight of what is important – do patients see in-care as specialty or general service?

We are one-on-one in the room with the patient. How do we get more people in the room in private practice? In hospitals they can work as a team because they can all get in the room. Some private practices have evolved to have others on the same site like nutritionists, clerks, mental health providers, etc.

We were mired in detail until we took a couple of steps back. We discussed residency in general, and several specific concepts emerged. One concept is the idea that people arrive at residency with different experiences and capabilities. They are part of a continuum of learning thatn continues through residency. Perhaps the required competencies and cognitive input for residency might be generic enough to be taught in medical school.

Another concept is that some part of residency ought to have a core to it. There could be branching that allows people to move into the direction of their career choice. It would provide an opportunity for residents to find their passion. The branching may vary for individuals. Some may want to get alternative education tools.

There may be cognitive and practice assessment. Practice assessment would include cognitive skills. The test must be independent. We differed on independence in residency. It is a question whether progress through residency should be based on attainment of competency rather than time spent. Do people mature at different rates? We want some way to measure the residents' responses to changes in pediatrics, etc.

We looked at guiding principles that ought to be incorporated into the education program. First is the notion of continuing education. Skills development ought to improve in practice and the program should improve. The program gives feedback to the individual and vice versa. Leadership is required. Individuals should lead teams or groups and be able to work with a broad array of people invested in medicine.

There should be a focus on career development as well.

Two big problems need to be solved this week. The first is outcome assessment of competency that is not time based. How can the acquisition of skills be judged in ways other than time spent – the calendar? The second is the effect of changing the curriculum on child health. How are we going to know whether anything we do here changes anyone other than ourselves?

Are people “done” when they are assessed to have achieved a competency? As program directors, that assumes everyone has the same skill level when they're done. There are varying degrees of being “good” at something. The better ones teach and mentor others. If a competency is leadership and mentoring, then individuals stay in that rotation.

You achieve competency and then it's a plateau. But, further experience refines our skills. To create an achievement approach drives the concept that competence is enough and doesn't encourage refinement. We want to be more than competent. We want to approach, not achieve, perfection.

Hospital service needs are a big part of education, but we all seek some shift in the balance of how education and training time is spent on an individual basis. Carol knows the most about this. There have already been dramatic changes. Our capacities to effect change are more than most think. We will have to consider this in future meetings. We will have to decide what is achievable. We will also have to understand unintended consequences.

We had a rich discussion about this. We should think of what could be rather than thinking there is no way we can change things. We should think of flexibility and have the conversation about the period near the end of residency. The overriding principle regarding continuing education is “are they going to be lifelong learners?” None of us can say what the new topic will be in 20 years. If we can graduate students to recognize that they need to pay attention to what is new and want to be proactive in continuing education, then we will succeed. The last four competencies focus on lifelong learning.

We talked about lifelong learning. We had three questions. How do you measure the different types of learning? Knowledge, skills, or patient/practice outcomes? Safety, quality? What about obesity? How do you motivate lifelong learning? Is it a trait or can it be taught? It is both? How do you deliver it?

Competencies include new discoveries and knowledge. It should include patient outcomes, but that is after the fact. There should be assessment of what the practice needs based on what the community and the provider needs. There should be intellectual exploration.

There are many modes and learning styles. Perhaps today's modes are not enough. Maybe we should use IPods. Do learning preferences impact styles? What role does socializing play? Web-based modes can be available for everyone. One-on-one mentoring and group mentoring can be related to practice plans. We need more simulation tools for skills learning. There should be a carrot as well as a stick for recertification and licensure.

Professional societies and academic centers as well as the government should be involved. Perhaps drug companies should be involved as well.

The stages include the Dreyfus Model. Each stage is dynamic. Knowledge and skills are included. Assessments should occur at each stage. Learners should assess their preferred learning styles up front.

During residency and medical school lifelong principles can be taught and encouraged.

Other stages after residency including consolidating knowledge and organizing your practice. You can mentor others. There is also the concept of transitioning to leave practice.

Should we select learners at medical school that present lifelong learning characteristics?

We suggest encouraging learning about other disciplines.

Are there simple principles or values for training and redesign that give us metrics for the whole project? How do we involve patients in this dialogue? What is the role of general pediatrics providers in the future? These are our questions for going forward.

What modes really get you to change? How should we measure if learning has occurred? Point-of-care learning is when you look things up when you are treating a patient. Can we get credit for that?

As a resident and a novice, you learn so well from the one or two patients for which you had to read about. In fellowship you teach. When you go into practice, you get to look things up but you don't get to present them like you did in training. We should teach those in training to be good teachers in the future. For those in practice, what ways are there to give them teaching opportunities? Is it internet based? Can we collaborate on-line to learn from each other like taking a picture of the rash and sending it to a colleague and getting advice?

The chances are you will be out on your own when you enter practice, so it is incumbent upon us to seek out learning, teaching and collaboration. The National Library of Medicine has a section on lifelong learning. They are aware of this problem and there is a dozen methods that are in practice. They are asynchronous and synchronous.

We focused on the medical school. Of all the instruction we have had in the last two days, the best was to avoid coming to early consensus. We have identified several ideas to bring forward.

We believe there are many new things for the box. We can remove redundancies, shift things and lengthen others. We focused on redundancies and shifting. We had no consensus on what could be removed. We came up with things that need to be added and it echoes what we have heard from other teams.

We want to shift some things in pre-medical education.

In medical school, we listed important topics to achieve the skills we should have at the end. We came to no agreement about basic sciences. We do believe that medical school changes are headed in the right direction. Changes should be anchored to objectives. Content areas should be integrated throughout the experience. Integration should help remove redundancies.

We think competency-based assessment should apply to medical school as well as residency.

We think we should plan and tailor rotations more to customize them. We focused on the fourth year of medical school. Could the fourth year be tailored in terms of clinical experience and basic science experiences that are tailored toward pediatrics if that is the chosen field? We had enthusiasm for continuing basic sciences in a tailored way through residency. We think we had so much trouble deciding about basic sciences because we haven't answered this question “what is the benefit of having a physician or pediatrician involved in child care relative to other providers?” We need to focus on this in the next round.

We agreed on the elimination of physics in the curriculum, but only because we had no physics majors in the group. [laughter]

Did you explore the ninth grade and determining career direction? It is implied. Do you want to use medical school as a liberal arts experience if you have already chosen pediatrics so early? Should some of the basic science issues be addressed in the pre-medical program, like biochemistry? It requires a very early commitment to medicine and that may not be practical.

You are almost better off having biochemistry, genetics, etc. in one course. Knowing probability and statistics is far more important than differential equations. We felt bio-statistics was a good name for that.

We need humanities, public health, psychology, etc., but we will run into turf wars.

If we had viable competency measures, would there need to be a fixed component to the curriculum? Could it be totally customized?

Our job was to summarize what we did in the prior exercise. We summarized key visions for the future and the controversial areas that require further discussion.

Key visions include the electronic medical record that is shared among the family's practitioners and members. It is necessary for an integrated future.

The Institute of Medicine 's quality of care will be implemented. It will be linked to CME and key competencies.

Teamwork means groups of providers that communicate and work together well. That will be for our residency students and others.

Regional area networks will be implemented.

We all used the term medical home, but we need to define the term. The controversy is “what will it be? Where will it be?”

Universal access is something we have to find a way to do. It does not necessarily mean a government-sponsored program.

We talked about family income disparities. They will persist.

Genomics will lead to predictive personalized medicine. Adequate compensation for providers is a must. Observation will be important to CME, not just lecturing.

What will the world look like in 2021? We don't know.

The controversial topics are the sticking points. Who will be the primary care provider? Will it be the pediatrician? What does continuity of care mean? One person or a hand off? There is a need for flexibility in residency. Tracking is something we're moving toward, but difficult to solve. The fourth year of medical school and number of years of training are hard issues we must solve in our project.

Where will the medical home be? Who will provide it? The primary provider might be different depending on region -- urban versus rural. One model will not fit all. Who will provide primary care for the medically-complex patients who deal with issues like cerebral palsy? Where will they do it?

Work life balance is important, but how will it affect care? If 50% of our workforce is part time, will that affect quality of care?

We have two questions. What will be the scope of pediatric practice in the future? Who will be the primary provider – the pediatrician or more like the British model?

Will hospital care be provided by the same person who sees them outside the hospital? What will the pediatrician's role be? The hospitalists'?

Who will provide mental health?

Pediatrics must come to terms with “how do you train people to be independent primary care providers?” The best programs give them experts at their right hands all the time. That is not true when they go out on their own in practice. People want the answers immediately and they gravitate to the person who can provide them most speedily. The question is being asked why pediatricians refer so many simple things headaches and like short stature. Not all short kids need an endocrinologist. The implication for training is not to customize it too much. Right now we only get a month per specialty like gastronology. We need to know what people need to know to function independently.

As we try to apply learning to private practice, learners are not receptive until they have the responsibility to make the decisions. The perception of people coming out of residency is that they are ready for practice but then they discover they are not ready. But, they are not receptive during residency to that type of training. It is an impasse at present.