PROPOSED INSTRUCTIONAL DESIGN TEMPLATE ON CHILD PROTECTION TRAINING IN THE PEDIATRIC RESIDENCY CURRICULUM
Bernadette J. Madrid, MD, FPPS
Melissa Joyce P. Ramboanga, MD, DPPS
Erlyn A. Sana, PhD
The Child Protection Network Philippines, Inc. presents this proposal integrating protection of children from abuse and neglect in the residency training for the approval of the Philippine Pediatrics Society, Inc. The commitment of both institutions to protect children from abuse and neglect, preserve, and promote their holistic development matches the global call for transformative health professions education. The course design is tailored to follow the national and international qualifications standards for Level 8 credentials in the Philippine Qualifications Framework.
The course design includes learning outcomes, minimum subject matter and instructional resources, and performance assessment following the outcome-based education curriculum design. Accredited individual training institutions are presented this template to help them implement the program while remaining true and faithful to their respective philosophies and core values.
Child protection refers to “preventing and responding to violence, exploitation and abuse against children – including commercial sexual exploitation, trafficking, child labor and harmful traditional practices, such as female genital mutilation/cutting and child marriage.” (UNICEF, 2016).
In the Philippines, doctors lag behind social workers, lawyers, judges and police officers in terms of their knowledge, skills and attitudes toward child protection. Since 2000, the Child Protection Network (CPN), in collaboration with its partner agencies have been conducting intensive trainings and on-the-job programs for these other professionals. Even though the child abuse and neglect curriculum has been introduced in the training of undergraduate medical students, further focused training is needed to ensure adequate competency in the management and prevention of cases of abuse and neglect. Since pediatricians directly interact and handle children and their families, they are the front-liners in the protection of children; however, studies have shown that may not be well- prepared for such cases.
A review of the Philippine Pediatric Society, ICD-10 Registry from January 1, 2006 to December 1, 2009 on the number of children who were abused or maltreated showed only a total of 15 cases in 4 years: 4 Physical abuse, 4 sexual abuse and 7 other maltreatment syndromes. On the other hand, there were 32 infants (Under 12 months) with multiple fractures of the extremities, fractures of the skull and facial bones and 1,351 children under 3 years with head injuries. This data implies poor recognition and underreporting of possible child abuse cases. Furthermore, a study done by Dela Paz, Madrid and Tan (2007) among Pediatric chief residents in the National Capital Region (NCR) revealed that 95% of the pediatric training programs in NCR do not have an existing curricula on child abuse and neglect (CAN). Figures also showed that 48% of the chief residents perceived their residents as somewhat prepared in identifying and evaluating cases of CAN while 33% perceived their residents as not well prepared. The most common aspects of CAN training identified as needing improvement were dedicated time for training and expertise of the CAN providers. The same conclusion was found in one study done among medical doctors in the United States of America (USA). Blumenthal and Gokhale (2014) evaluated the preparedness of American physicians to handle certain types of patients and medical conditions. They found that 11-12% of primary care residents, which included pediatricians, were unprepared to handle domestic violence and child maltreatment cases. Another research showed that 52% out of the 200 surveyed pediatricians in Alabama, USA felt that they were not competent in conducting sexual abuse examinations, and 16% felt incompetent in examining physically abused children, despite the fact that 20-30% of the respondents were already involved in child abuse physical and anogenital examinations (Arnoid, et al., 2005).
Integrating child protection in the pediatric residency training is aligned with the overall goal of the training program of the Philippine Pediatric Society, Inc. of providing doctors with the opportunity to be proficient in the “preventive, promotive, curative and rehabilitative aspects in the practice of pediatrics (PPS, 2013).” This is also consistent with the objective of preparing future pediatricians for general practice. Given the increasing awareness towards child abuse and neglect, its increasing number of cases and its physical, mental, emotional and social effects on children victims, child protection issues will surely be a part of one’s pediatric practice. One should be ready to face any child abuse and neglect case in the future, because cases like these entail the help of any medical practitioner at any point in time, regardless of being involved in a government-run or private practice.
The module on child protection is just one of the many topics that a pediatric resident must learn during the three years of pediatric specialty training. This part of the training will focus on the recognition of the different types of child maltreatment in all pediatric cases that may be encountered in both the out-patient and in-patient setting. Once recognized, the module will also help the doctor learn the skills necessary in documenting these cases, as well as in providing the crucial frontline interventions for these children. Lastly, through the mixture of classroom-type activities and on the job patient encounters, the future pediatricians of the country will become advocates for the best interest of the Filipino child as well.
This instructional design was made for doctors who will undergo the three-year pediatric residency training through the recommended curriculum of the Philippine Pediatric Society (PPS) at accredited training hospitals in the Philippines. The number of students may range from a minimum of 2 to a maximum of 25, depending on the training institution.
This course design will be implemented by accredited hospitals that offer pediatric residency training in the Philippines. Since these training institutions are categorized into four levels based on the Philippine Pediatric Society Hospital Accreditation Board recommendation, how it will be integrated into their training program will rely on the number of trainees and the resources available. Training officers are encouraged to adopt the teaching and learning, as well as evaluation strategies that are relevant to their respective contexts.
The course design will require a meeting room or a conference room, as well as hospital clinics and wards for a variety of settings to learn application of concepts and skills.
It is recommended that the classroom-type activities, geared toward the acquisition of knowledge and skills on child protection, be introduced in the first year of residency training and reiterated throughout the rest of the three years of training. Application of learned concepts and skills will be through patient encounters in the clinics, emergency room and wards, which may begin during the first year of training, but this should be more evident in the second to third years.
Let us insert here the general program outcomes of residency training in pediatrics if PPS already has these. Then we insert a sentence that these CAN learning outcomes are consistent and aligned with PPS.
At the end of the Pediatric Residency Training, the pediatric resident must be able to:
- Recognize child abuse and neglect among pediatric patients in the out-patient and in-patient settings.
- Document suspected child maltreatment cases that may be encountered in clinical practice.
- Provide multi-disciplinary intervention to suspected abused and neglected children, through timely reporting to necessary agencies and referring to relevant disciplines and agencies.
- Advocate for the best interest of the child at all times in clinical practice.
For each outcome, there will be at least two learning strategies that may be implemented. One is meant to provide the basic knowledge, skills and attitudes related to child protection, and the other is meant for their application in clinical practice during residency. Sometimes, different learning strategies may be presented, to serve as options; however, their implementation will depend on the resources and capability of the training institution. Assessment of achievement may include examinations, case conferences and case reports. The teaching and learning and assessment strategies may be spread out through the three- year pediatric residency program, as long as the outcomes are achieved by the end of training.