Perceptions of 24/7 In-house Attending Coverage on Fellow Education and Autonomy in a Pediatric Cardiothoracic Intensive Care Unit

High variability in cardiac education and experiences during United States paediatric critical care fellowships

BACKGROUND

Paediatric cardiac critical care continues to become more sub-specialised, and many institutions have transitioned to dedicated cardiac ICUs. Literature regarding the effects of these changes on paediatric critical care medicine fellowship training is limited.

OBJECTIVE

To describe the current landscape of cardiac critical care education during paediatric critical care medicine fellowship in the United States and demonstrate its variability.

METHODS

A review of publicly available information in 2021 was completed. A supplemental REDCap survey focusing on cardiac ICU experiences during paediatric critical care medicine fellowships was e-mailed to all United States Accreditation Council of Graduate Medical Education-accredited paediatric critical care medicine fellowship programme coordinators/directors. Results are reported using inferential statistics.

RESULTS

Data from 71 paediatric critical care medicine fellowship programme websites and 41 leadership responses were included. Median fellow complement was 8 (interquartile range: 6, 12). The majority (76%, 31/41) of programmes had a designated cardiac ICU. Median percentage of paediatric critical care medicine attending physicians with cardiac training was 25% (interquartile range: 0%, 69%). Mandatory cardiac ICU time was 16 weeks (interquartile range: 13, 20) with variability in night coverage and number of other learners present. A minority of programmes (29%, 12/41) mandated other cardiac experiences. Median CHD surgical cases per year were 215 (interquartile range: 132, 338). When considering the number of annual cases per fellow, programmes with higher case volume were not always associated with the highest case number per fellow.

CONCLUSIONS

There is a continued trend toward dedicated cardiac ICUs in the United States, with significant variability in cardiac training during paediatric critical care medicine fellowship. As the trend toward dedicated cardiac ICUs continues and practices become more standardised, so should the education.

Guiding Fellows to Independent Practice: Current Trends in Pediatric Emergency Medicine Fellow Supervision

BACKGROUND

Recent studies highlight the importance of physician readiness to practice beyond graduate training. The Accreditation Council for Graduate Medical Education mandates that pediatric emergency medicine (PEM) fellows be prepared for independent practice by allowing "progressive responsibility for patient care." Prior unpublished surveys of program directors (PDs) indicate variability in approaches to provide opportunities for more independent practice during fellowship training.

OBJECTIVES

The aims of the study were to describe practices within PEM fellowship programs allowing fellows to work without direct supervision and to identify any barriers to independent practice in training.

DESIGN/METHODS

An anonymous electronic survey of PEM fellowship PDs was performed. Survey items were developed using an iterative modified Delphi process and pilot tested. Close-ended survey responses and demographic variables were summarized with descriptive statistics. Responses to open-ended survey items were reviewed and categorized by theme.

RESULTS

Seventy two of 84 PDs (88%) responded to the survey; however, not all surveys were completed. Of the 68 responses to whether fellows could work without direct supervision (as defined by the Accreditation Council for Graduate Medical Education) during some part of their training, 31 (45.6%) reported that fellows did have this opportunity. In most programs, clinical independence was conditional on specific measures including the number of clinical hours completed, milestone achievement, and approval by the clinical competency committee. Reported barriers to fellow practice without direct oversight included both regulatory and economic constraints.

CONCLUSIONS

Current training practices that provide PEM fellows with conditional clinical independence are variable. Future work should aim to determine best practices of entrustment, identify ideal transition points, and mitigate barriers to graduated responsibility.

Defining Supervision Preferences and Roles Within a New Subspecialty: Pediatric Hospital Medicine

OBJECTIVE

To describe supervision preferences among pediatric hospitalists, Pediatric Hospital Medicine (PHM) fellows, and senior residents (SRs), and to better define the ideal role of a PHM fellow.

METHODS

We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys, one for each population (hospitalists, fellows, SRs). We calculated univariate descriptive and bivariate statistics for categorical variables using Chi-square tests with the Rao-Scott correction to account for clustering by institution.

RESULTS

Survey respondents included 106 of 200 hospitalists (53%), all 20 fellows (100%), and 149 of 380 SRs (39%). Most hospitalists and all fellows preferred the supervising hospitalist to have 3+ years of experience or be fellowship-trained. Nearly all fellows preferred the attending round in-person providing progressive independence; while hospitalists and SRs desired greater attending presence on rounds. Hospitalists and fellows wanted more frequent communication when the attending does not round with the team, and more hospitalists desired at least 2 points of contact regardless of attending presence on rounds. Fifty-five percent of SRs reported experiencing much less/less autonomy when on with a fellow than when supervised by a hospitalist only. Regarding the fellow's role, most participants agreed SRs should lead rounds and contact the fellow first with questions. The majority agreed teaching should be a shared responsibility but lacked consensus about how to provide feedback.

CONCLUSIONS

Study results reveal preferences about supervising fellows in this new subspecialty. Hospitalists, fellows, and SRs may have differing opinions regarding workflow, communication, and teaching, impacting team leadership and autonomy.

Effect of 24/7 attending coverage in the neonatal intensive care unit on fellow education

BACKGROUND

There is a current change in type of attending coverage in the Neonatal Intensive Care Unit (NICU) from home calls to 24/7 in house coverage. Effects of this increased attending physician presence on education of NICU fellows has not been studied. The objective of this study is to evaluate the fellows' perception of in house attending coverage on their education and evaluate its effect on their perceived autonomy.

METHODS

A secure, anonymous, web-based survey was designed using RedCap. The web-based survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training & Early Career Neonatologists. Questions were focused on perception of IH attending coverage on fellows' educational experience including the respondent's perceived ability to make independent decisions (autonomy). Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small.

RESULTS

One hundred and twenty-three surveys were analyzed, that included responses from 82 fellows & 41 early career neonatologists. 52% reported having 24/7 attending in-house (IH) coverage. Thirty of the 123 respondents experienced a change in model of attending coverage during their training. Among these 30, only 26.6% preferred the model of attending IH coverage. The respondents currently working in IH models, when compared to those in non-IH coverage models felt IH attending coverage was beneficial for fellow education (p < 0.05) but was less likely to give fellows autonomy for decision making (p = 0.02).

CONCLUSION

In our survey respondents with in house attending, had a more favorable view of its benefit on fellow education. Institutions practicing or considering IH attending coverage should consider use of adequate measures to balance fellow supervision and education.

Creating and Sustaining a Successful Fellowship Program: Challenges and Solutions

Subspecialty expertise and fellowship training are two of the most desirable attributes in new radiology hires and, not surprisingly, the vast majority of diagnostic radiologists entering the job market today have had fellowship training. Fellowship training imparts not only expertise beyond that which is attainable during residency, but also a unique opportunity for professional maturation. In this article, we offer guidance in planning, building and sustaining a successful fellowship. The key steps in this process include strategic planning, development of a curriculum that can be customized to meet the educational goals of any individual fellow, professional development and trainee preparation for the marketplace, and approaches to ensure program longevity and success through local, regional and national fellow recruitment efforts. While many of the ideas presented are framed from the perspective of their integration into a newly formed fellowship program, they can also be adapted for use by existing fellowship programs as opportunities for program growth and improvement.