When Eileen Ouellette, MD, graduated from Boston’s Harvard Medical School in 1962, she was one of seven women in her class of 141 students. She went on to become one of only three women in pediatric residency at Massachusetts General Hospital later that year.

Free room and board was included in the program, Dr. Ouellette recalled, but her cramped room was poorly insulated and so small that she had to kneel on the bed to open her chest of drawers. The young doctor also soon learned that the women residents made less money than their male counterparts.

“We were paid $800 a year, which turned out to be $64.04 a month,” said Dr. Ouellette, a past president of the American Academy of Pediatrics (AAP). “The men were given $1,200 a year because [the residency program] figured they needed it more. I, for one, complained every single day for the whole year. The second year, we all got the same pay – $1,600 – so our complaints had done something.”

Dr. Ouellette, 79, now can laugh at the memory of her tiny room and tinier paycheck. The pediatric residents of today are entering a vastly different environment, she said. For starters, the average pay for medical residents in 2017 is $54,107. Women pediatric residents today far outnumber male residents. And most residents enjoy standard-sized rooms or apartments when completing their residencies.

When Dr. Renee Jenkins completed pediatric residency in the early 1970's, there were no separate on-call sleeping rooms for women so both genders slept in the same room. But it didn't matter, she says, "We were all tired."

Pediatric residency has undergone a plethora of other changes over the last 50 years, from decreased work hours to increased technology, more student debt, and fewer clinical responsibilities. Some of the changes have burdened residents’ time, while other shifts have improved their practice experience, long-time pediatricians say.

Technology, for instance, greatly aids pediatric residents in their education today, said Renee Jenkins, MD, a professor at Howard University in Washington and a past AAP president.

“I remember, in the old days, going to the National Library of Medicine and ordering an article,” said Dr. Jenkins. “There are so many benefits [today], for the most part. Residents are more electronically driven and that puts them so much further ahead in terms of knowledge acquisition [and] checking on practice standards. There’s more help for them now.”

Fewer hours, more hand-offs

During Dr. Ouellette’s residency from 1962 to 1965, sleep became a luxury. Of 168 hours in a week, residents were sometimes off for only 26 of them, she said.

“That was absolutely brutal,” she said. “You could not think of anything other than sleep. That became the primary focus of your whole life.”

By the 1970s, many programs had reduced their work hours for residents. Bonita Stanton, MD, who attended residency from 1977 to 1980 at what is now Rainbow Babies and Children’s Hospital in Cleveland, remembers working every third night.

“It didn’t seem crazy at the time,” said Dr. Stanton, founding dean of Seton Hall University Hackensack Meridian School of Medicine, South Orange, N.J. ”You developed the kind of bond with these families that it wouldn’t occur to you to go home.”

In the 1960s, there were no explicit limits on duty hours, according to Susan White, director of external communications for the Accreditation Council of Graduate Medical Education (ACGME). A “Guide for Residency Programs in Pediatrics,” published in 1968, recommended that “time off should be taken only when the service needs of the patients are assured and that “night and weekend duty provides a valuable educational experience. ... Duty of this type every second or third night and weekend is desirable.”

The guide predates the existence of the ACGME – established in 1981 – but it originated from a committee approved by the American Academy of Pediatrics, the American Board of Pediatrics, and the Council on Medical Education of the American Medical Association, according to Ms. White. While some residency programs changed their work hours over the years, the first mandated requirements for duty hours came in 1990 when ACGME set an 80-hour work week for four specialties: internal medicine, dermatology, ophthalmology, and preventive medicine. The council also limited on-call to every third night that year. In 2003, ACGME put in place duty hour requirements for all specialties.

Dr. Bonita Stanton practiced in Bangladesh in the mid-1980s after her pediatric residency in the late 1970s.

Revisions to the Common Program Requirements made in 2017 now allow a maximum of 24 hours for all residents starting in the 2017-2018 academic year.* Resident programs today also have explicit standards and policies for institutions, programs, and residents regarding patient safety and supervision and physician well-being.

“The pediatric requirements currently in effect provide safeguards for the resident, guidelines for educational programs, specific competencies and medical knowledge, as well as communication skills, professionalism requirements, and standardized assessment,” Ms. White said.

Current limitations for duty hours are beneficial in terms of resident safety, but the restrictions can be a double-edged sword, Dr. Jenkins said.

A "Guide for Residency Programs in Pediatrics" that was published in 1968.

“The question is ‘Did they go past the dial to the other side?’ ” she said. “I think there are some real issues about secure and safe hand-offs of patients when you have work hours that are shortened. [It’s] a balance of trying to weigh the demands of one side and safety of patients on the other side.”

A changing gender demographic

By the time Dr. Stanton graduated from Yale in 1976, about 15% of her class were women, a marked shift from just a few years earlier, she said.

“In my residency program, women made up a quarter of our group,” she recalled. “That was a big change.”

The number of women going into pediatric residency has steadily increased in the last 5 decades, now far surpassing the number of men. Of 8,933 pediatric residents from 2015 to 2016, 67% were female and 25% were male, (with 8% not reporting), according to ACGME data.

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There has been a steady and significant shift in gender within the field of pediatrics, with female pediatricians now representing the majority of the pediatric workforce and constituting 70% of the those training to be pediatricians,” said Nancy Spector, MD, a professor of pediatrics and executive director of the executive leadership in academic medicine program at Drexel University, Philadelphia.

Pediatrics is a natural selection for women, especially for those who plan to raise families, said Antoinette Eaton, MD, a retired pediatrician who completed her residency in the late 1950s at what is now Nationwide Children’s Hospital in Columbus, Ohio. Pediatrics is a prime specialty for career and family balance, she said.

“I worked part time a lot during my career,” said Dr. Eaton, a past AAP president. “Always being responsible as a mother and to the house were very high priorities.”

Dr. Stanton agrees that pediatric practices are much more tolerant of part time work, allowing women to better juggle children and career. However, she notes that the decline of male pediatricians also can be negative for the field overall.

“We want role models for young boys growing up,” she said. Plus, “it’s fun to have a diversity of colleagues around you.”

New focus, growing debt

The curriculum focus for pediatric residency, meanwhile, has changed significantly over the years, pediatricians say. Dr. Eaton recalls her residency being almost entirely focused on inpatient care. In fact, insurance companies often refused to pay for outpatient care in sharp contrast to today, she said.

“You had to admit the patient if you wanted insurance to pay for it,” she said. “For example, if you had a patient with cerebral palsy or special needs, I had to admit that patient for 3, 4, 5 days. It was really different than what you have today.”

As time has passed, pediatric requirements have changed to emphasize the need for balance between inpatient and outpatient care, with a focus on continuity of care in either setting, Ms. White said. Newer additions to the requirements include the competencies of professionalism, communication, and life-long learning.

“Over the years these setting have expanded to include inpatients in hospitals, clinics, emergency centers, intensive care units, and in the community, [including] schools and other settings,” she said. “The requirements have always emphasized the importance of having high-quality, board-certified faculty to provide bedside teaching and deliver lectures at conferences.”

Another marked change for pediatric residents is the accumulation of debt. After her medical education, Dr. Jenkins owed about $1,500, she recalls.

“Today, that’s a drop in the bucket,” she said. “For the most part, you stayed out of [debt] trouble. It was nothing compared to that kids have to pay now.”

In 2014, the average medical school student graduated with a median debt of $180,000, according to data from the Association of American Medical Colleges. The wide debt differences are attributed to more expensive medical education today, Dr. Jenkins said.

While debt has risen, clinical responsibilities for residents have dropped as physician extenders and advanced equipment have become commonplace.

When Dr. Ouellette was a resident in the 1960s, there were few technicians to assist and no CT scans or MRIs for imaging. Residents drew blood from and gave blood to patients themselves. They took x-rays and developed them, she said.

“We had to use our brains and figure out what was going on,” she said. “People don’t think so much now. They send x-rays or scans to someone else, rather than figuring out the answer. Medicine may not be as much fun now as it was back then.”

Dr. Eaton added that residents have more technical demands today, more regulations to follow, and more paperwork to complete than the residents of the past. However, she believes pediatrics remains a worthwhile medical path. Three of her four children became doctors, one of whom went into pediatrics.

“I’m very disturbed when people try to convince children not to go into medicine,” she said. “I think it’s still a wonderful and rewarding career.”

agallegos@frontlinemedcom.com

On Twitter @legal_med

*Clarification made on 4/21/17

50 years of pediatric residency: What has changed?