Protected Time, Real Impact: How Pediatric Residents Can Foster Longitudinal Community Partnerships through Health Equity Tracks

How a pediatric residency built protected, longitudinal time for community partnership, and what it would take for other programs to do the same.

Health Equity Work in Residency

The traditional structure of most residency programs leaves little room for sustained community engagement. Call schedules and prolonged inpatient blocks often limit residents’ ability to develop longitudinal partnerships outside hospital walls. Community organizations cannot count on residents for dependable work. While there are examples of advocacy in later iterations of pediatricians’ careers,¹ pediatric residents find their demanding clinical work as a hindrance from developing these skills during residency.

Given the time constraints, many residency programs offer experiences with one-time volunteer projects, where residents volunteer for a few hours and never return. However, recent updates in Accreditation Council for Graduate Medical Education (ACGME) guidelines on advocacy opportunities create an impetus for pediatric residency programs to challenge the status quo of one-time community engagements.² While one-and-done events may satisfy advocacy graduation requirements, residents can offer much more to the communities around them.

Our Project

When we began our residency, we recognized the need for more overdose prevention education for adolescents.³ In our local community of Washington, there is a disproportionate burden of opioid overdose deaths (OODs) among adolescents and young adults compared to other U.S. states.⁴ Racial and ethnic inequities in OODs are rampant nationally,⁵ including in our local community.⁶ In partnership with school staff, residents supported high school students in developing a student-led overdose awareness initiative that led to increased distribution of naloxone kits through the school-based health center.⁴ Without structured support and protected time afforded by our health equity track (HET), we as residents would not have had the capacity to develop this community-based partnership.

Structure of HET

While all residencies should focus on strategies to interrupt inequities, there is still a need for dedicated time for residents to address these issues alongside the communities that experience them. For residents who wish to continue equity work in their future careers, a dedicated track within residency is necessary while maintaining other requirements of a pediatric residency. In conceiving the University of Washington Pediatrics Health Equity Track, we centered shared learning, structured mentorship, and community building. In practice, this is a four-week curriculum block shared between all residents each year, plus an additional sixteen weeks during R2 and R3 years (4 blocks or spread between X+Y blocks if using this model) to continue to advance scholarship (Figure 1 and Figure 2).

The ACGME requirements for pediatric residents dictate that a pediatric resident’s individualized curriculum should consist of “a minimum of 20 weeks of elective clinical, scholarly, and/or other experiences.”² As contrasted with the categorical track, HET time replaces a combination of inpatient and subspecialty electives, though HET residents still have a minimum of four weeks of elective time per year.

Shaded cells mark HET time. Each block is four weeks.

During the curriculum block, experts and community members are invited to discuss their expertise, spanning a wide array of issues ranging from different forms of advocacy, skills-building workshops, narrative reflection, and care of specific, marginalized populations. Invited speakers may be within the medical sphere or community members doing work within health equity or adjacent fields. Residents learn early that this work cannot be done in silos, and that interdisciplinary learning and collaboration is necessary. Residents are afforded time to build relationships with speakers and develop partnerships aligned with their interests.

HET faculty are paired with HET residents for individualized mentorship, and residents receive guidance through mentorship committees that consist of other physicians both within our institution and at other institutions with similarly aligned work or career goals as the resident. Faculty on each mentorship committee facilitate introductions to academic and community partners, enabling residents to collaborate on legislative advocacy, research, program development, and community partnership. With this comprehensive model, our residents can successfully take an intentional and sustainable approach to community partnership in their early training.

To date, there have been 2 graduating classes (8 individuals) of HET residents, with 3 classes (12 individuals) currently enrolled. Early evaluation of HET, including career outcomes and sustainability of community partnerships, is underway and will be reported in future work.

Shaded cells mark HET time. Each Y week in years 2 and 3 is partially highlighted green to stand for the HET time included in that week.

Application to Other Specialties

The protected elective time for equity-focused work, interdisciplinary mentorship committees, and longitudinal community partnerships promoted by HET are readily transferable across graduate medical education. A systematic review of graduate medical education advocacy curricula found that specialties like internal medicine, family medicine, pediatrics, and psychiatry programs had training opportunities aimed to help residents identify community partnerships, develop experiential learning, and sustain project-based work.⁷

Specific examples across specialties have been identified in the literature. Tulane University’s Advocacy and Leadership Track and Cambridge Health Alliance have both implemented longitudinal curricula and projects aimed to equip residents to take on advocacy and equity-based work.^8,9 Penn State Family Medicine and Community Health, for example, has a longitudinal community curriculum in population health with the goal to create sustained community engagement from trainees after graduation.¹⁰

Programs across specialties that have adopted X+Y scheduling models are well-positioned as the predictable outpatient blocks create natural opportunities for sustained community engagement without disrupting inpatient coverage. What distinguishes HET from existing efforts is not the content but the commitment of protected, longitudinal time and formal mentorship infrastructure.

Limitations

While we believe HET is both easily implemented and sustained, there are limitations to consider when creating similar programs. This is a matched track that requires ACGME accreditation, so programs aiming to replicate these efforts need to dedicate appropriate resources to do so. In addition to recruiting core faculty to support such a program, the ACGME details specific requirements around allocation of full-time equivalents (FTE) for program leadership, core faculty, and administrative personnel for a program.

One other consideration is the impact on inpatient staffing. Many hospitals rely heavily on resident labor, and large shifts in resident schedules could compromise patient care if not done thoughtfully. One way to address this is to allocate the majority of protected time through the ACGME’s elective requirements to minimize the impact on inpatient staffing while still providing this essential opportunity.

Recommendations for Residency Programs

We believe there are practical and sustainable lessons for the health equity track that can be applied to other residency programs and recognize that realities at other programs may impede broad uptake.

• Residencies forming a similar track should consider which aspects of a resident’s “individualized curriculum” could be replaced with a health equity track.
• Pediatric training programs moving to X+Y schedules offer an opportunity for community engagement to be incorporated more concretely into training.
• Mentorship committees can guide residents to develop equity-focused professional portfolios, positioning them for equity-focused careers.

Call to Action

It is essential for residency programs to create opportunities, like this health equity track, to train residents in the creation of meaningful relationships with communities to promote health equity. Limited funding may make implementation of these dedicated tracks difficult, but it is crucial for residents and program leadership to invest their existing resources into their surrounding communities. However, these types of dedicated tracks can fit inside elective time residency programs already have, which may allow for flexibility in terms of redirection of existing staff (having elective rotation leadership and administrators take on alternative models of these protected blocks). Community partnerships, when developed intentionally, can foster collective action through pooling resources, knowledge, and energy needed to fight health inequities. Enlisting residents as agents of change not only addresses current inequities but energizes them to champion this work throughout their careers.

Contributors Statement: Dr. Thomas Agostini conceptualized the content for this article, wrote, and edited the paper in full. Dr. Adriana Herrera critically reviewed the article and edited the paper in full. Dr. Elizabeth Dawson-Hahn critically reviewed the article and edited the paper in full. Dr. Sabreen Akhter wrote the section on the creation of protected time and supporting residents. She also critically reviewed the article and edited the paper in full. All authors agree to be accountable for all aspects of the work.

Acknowledgments: Authors acknowledge the use of OpenEvidence (https://www.openevidence.com/) to refine the academic language, check for grammatical errors, search for similar academic publications, and make recommendations to make the writing more concise. Authors followed guidance by the International Committee of Medical Journal Editors for artificial intelligence, and the software was not used to generate original content, text, or analysis. Suggested changes by the software were reviewed by the authors closely for accuracy and modified for the final submission.

Funding: All phases of the referenced project in this article were supported by the University of Washington Population Health Initiative’s Tier 1 Pilot Grant.

Conflicts of Interest: The authors have no conflicts of interest to disclose.