The Challenges of a Necessary Increase in Pediatric Training During Emergency Medicine Residency

Included in the major revisions recently proposed by the Accreditation Council for Graduate Medical Education (ACGME) to the program requirements for residency training in Emergency Medicine (EM) are recommendations for increased training in pediatric emergency care [1]. Currently, most children seeking emergency care in the United States present to general emergency departments (EDs), where they are cared for by the graduates of residency programs that require only 5 months of pediatric training [2]. Making the case for this attention to pediatric education are needs assessments and case logs, in which graduates report feeling unprepared or are found to lack exposure to pediatric ages or conditions that they might encounter in practice [3, 4]. The ACGME's emphasis on infants and children under 12 years, with a specific aim to achieve exposure to neonatal resuscitation, seems to address reports that younger ages are the most anxiety provoking for EM physicians [5, 6]. Everything proposed by the ACGME is logical and important, but the feasibility of attainment is another matter. The reality is that exposure to specific aspects of pediatric EM is impossible to guarantee, and varied interpretation of the suggestions incites confusion and concern in the medical educators responsible for making these changes. Compliance with the new recommendations poses challenges that we must recognize and address in order to do what is right for future trainees and the young patients they will care for.

The first challenge many programs will encounter is reliable access to both sufficient pediatric patients and sufficient pediatric expertise. While residents will be able to count pediatric patients seen in community ED settings toward the total time required, most EDs care for fewer than 15 children per day and more rural settings see fewer than five children per day [7, 8]. In a proposed edit to the ACGME recommendations, the Emergency Medicine Residents' Association (EMRA), which is supportive of the recommendation for 24 weeks of pediatrics during training, suggests 1000 pediatric encounters and 18 weeks of pediatric ED time [9]. They note that this amounts to 1.23 children per hour over 18 weeks. It remains to be seen if either metric is achievable in a variety of settings, especially if the new focus is on children under 12 years old.

Furthermore, many communities lack access to inpatient pediatric care, leaving EM residencies in these areas a dearth of learning opportunities [10]. As a result, both travel to and volume of trainees at certain pediatric sites will increase, which creates its own set of challenges. The ACGME is aware that being away from home during training is a burden: there is language in the program requirements advising that accredited rotation sites over 60 miles, or 30 min, from the home institution must be approved by the Residency Review Committee in order to limit any undue travel [1].

Another point worthy of discussion is the specification of ideal age ranges for pediatric emergency education, including attention to neonatal resuscitation. While the ACGME does not mandate that the timing of neonatal resuscitations experienced and led by EM residents should be immediately after delivery, they also do not advise educators on how to interpret this recommendation. Per the American Academy of Pediatrics, a neonate is an infant in the first 28 days of life, and “it is the period of the most dramatic physiologic changes of human life” [11]. For this reason, the Society for Academic Emergency Medicine's Pediatric Special Interest Group suggests both leveraging the exposure to the newly born during obstetric rotations and expanding the concept of neonates to include all babies who meet the true definition of this age group. There are residency programs that have crafted well-received neonatal intensive care unit (NICU) rotations for EM residents [12], and this likely enhances a trainee's sense of preparedness for a future ED delivery, but there are many other emergent issues during the full neonatal time frame deserving of attention and preparation. EM residents would likely appreciate any education about these young ages, as they desire more training related to neonates but also feel unprepared for older infants, and they admit to fear of sick infants presenting to their EDs [3, 5].

The new recommendation emphasizes exposure of trainees to children under 12 years old since “adolescent patients between 12 and 21 years are anatomically and physiologically similar to adults,” but residents “will continue to treat adolescents” [1]. This secondary comment is important: as one considers the need to meet certain targets, a true limitation by age would certainly hinder success. If trainees are being sent to pediatric centers for these rotations, it would hardly seem reasonable to suggest that the pediatric providers care for all the teens; in fact, that would likely hamper the relationship with that affiliate to some degree. Additionally, teens are quite different from adults. For example, pediatric trauma surgeons remind emergency physicians that teen trauma patients have intense caloric demands that must be met to support wound healing, and they should be managed accordingly. Importantly, the behavioral health crisis in this country is experienced differently by teens, as developmental delay and psychosocial factors in this population contribute to a lack of access to appropriate disposition plans for them, resulting in increased risk in morbidity and mortality [13]. Emphasis on the resuscitation of children who are physiologically distinct from adults seems fair; elimination of exposure to those older than 12 years entirely would likely create a gap in training with long-lasting impact and is not likely in the spirit of what the ACGME intends.

If the ACGME's recommended changes to EM residency are adopted, the residency programs in this country will need to adapt. Pediatric exposure alone will not be adequate. While it makes sense to add time or case numbers to increase the potential for achieving learning goals, there is no guarantee that a set volume or age of child will present to any ED. Creativity and curriculum building will be essential. During the COVID-19 pandemic, pediatric presentations to ED settings, even primarily pediatric EDs, plummeted before dramatically rebounding [3], and educators were forced to supplement training in any way they could. While EM physicians report that experience and exposure are key to establishing comfort in caring for children, they also recognize the value in simulation and other educational adjuncts, such as training via the Neonatal Resuscitation Program (NRP), as ways to enhance preparedness for the pediatric population [6]. If simulations can count toward ACGME requirements, they can focus on specific ages or pathology, thereby helping to make the unpredictable nature of EM less intimidating. Tele-simulation may be of some benefit for more rural or otherwise remote programs with limited access to pediatric centers or expertise [8].

Additionally, it is vital to emphasize that these changes will demand flexibility from both the ACGME and those interpreting the new requirements. Reliance on chronological age alone may be too strict and too challenging to track. Resuscitation of a 3-day-old or a prepubertal and growth-restricted 14-year-old should help to satisfy the need for experience with neonatal and pediatric resuscitations, respectively. If programs are meant to record pediatric exposure, it is worth considering the challenges imposed by tracking patients by age. At present, programs can pull data on patients under 18 years, so a true focus on those under 12 years implies implementation of a change in data analysis that could be a significant burden. Some programs likely have the technology and support to run this data easily, but even those well-resourced residencies will fail to count the cases that may have contributed to knowledge attainment despite falling outside a strict age range. Some programs will leave the tallying task to trainees or to program staff who have not previously done such work, making it worth considering if this effort justifies the cost in either time or money.

In a thoughtful perspective piece on the ACGME changes to the requirements for pediatric residency training that took effect in 2025, pediatric educators noted that the changes advised would pose financial and logistical challenges, but they concluded that the changes would benefit the education of the future pediatricians in this country [14]. The proposed increase in pediatric exposure and education for EM residents will likely pose the same challenges. By thoughtfully approaching the issues raised here, the specialty of EM can and should also make changes to support both our nation's children and the EM physicians who will care for them.

The authors declare no conflicts of interest.