Pediatric Intern Clinical Exposure During the COVID-19 Pandemic

Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review

PURPOSE

This study systematically reviews the uses of electronic health record (EHR) data to measure graduate medical education (GME) trainee competencies.

METHOD

In January 2022, the authors conducted a systematic review of original research in MEDLINE from database start to December 31, 2021. The authors searched for articles that used the EHR as their data source and in which the individual GME trainee was the unit of observation and/or unit of analysis. The database query was intentionally broad because an initial survey of pertinent articles identified no unifying Medical Subject Heading terms. Articles were coded and clustered by theme and Accreditation Council for Graduate Medical Education (ACGME) core competency.

RESULTS

The database search yielded 3,540 articles, of which 86 met the study inclusion criteria. Articles clustered into 16 themes, the largest of which were trainee condition experience (17 articles), work patterns (16 articles), and continuity of care (12 articles). Five of the ACGME core competencies were represented (patient care and procedural skills, practice-based learning and improvement, systems-based practice, medical knowledge, and professionalism). In addition, 25 articles assessed the clinical learning environment.

CONCLUSIONS

This review identified 86 articles that used EHR data to measure individual GME trainee competencies, spanning 16 themes and 6 competencies and revealing marked between-trainee variation. The authors propose a digital learning cycle framework that arranges sequentially the uses of EHR data within the cycle of clinical experiential learning central to GME. Three technical components necessary to unlock the potential of EHR data to improve GME are described: measures, attribution, and visualization. Partnerships between GME programs and informatics departments will be pivotal in realizing this opportunity.

Virtual Reality to Assess Resident Recognition of Impending Respiratory Failure During COVID-19

OBJECTIVES

To assess the performance of pediatric residents in recognizing a decompensating patient with impending respiratory failure and appropriately escalating care using a virtual reality (VR) simulated case of an infant with bronchiolitis after an extended period of decreased clinical volumes during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Sixty-two pediatric residents at a single academic pediatric referral center engaged in a 30-minute VR simulation on respiratory failure in a 3-month-old admitted to the pediatric hospital medicine service with bronchiolitis. This occurred in a socially distant manner across the Zoom platform during the COVID-19 pandemic (January-April 2021). Residents were assessed on their ability to (1) recognize altered mental status (AMS), (2) designate clinical status as "(impending) respiratory failure," and (3) escalate care. Statistical differences between and across postgraduate year (PGY) levels were examined using χ2 or Fisher's exact test, followed by pairwise comparison and posthoc multiple testing using the Hochberg test.

RESULTS

Among all residents, 53% successfully recognized AMS, 16% identified respiratory failure, and 23% escalated care. No significant differences were seen across PGY levels for recognizing AMS or identifying respiratory failure. PGY3+ residents were more likely to escalate care than PGY2 residents (P = .05).

CONCLUSIONS

In the setting of an extended period with decreased clinical volumes during the COVID-19 pandemic, pediatric residents across all PGY levels demonstrated challenges with identifying (impending) respiratory failure and appropriately escalating care during VR simulations. Though limited, VR simulation may serve as a safe adjunct for clinical training and assessment during times of decreased clinical exposure.

Where Do We Go from here? Post-pandemic Planning and the Future of Graduate Medical Education

Background

As the pandemic wanes, there is an opportunity to reevaluate resultant changes in graduate medical education (GME), particularly from the viewpoints of those affected most. We aimed to assess both trainee and faculty perceptions on the educational changes and innovations resulting from the pandemic to inform future educational planning.

Methods

We surveyed trainees and core education faculty at three New York City children's hospitals. Surveys assessed perceived changes to educational activities, skills, scholarship, effectiveness of virtual teaching, future desirability, and qualitative themes.

Results

The survey was completed by 194 participants, including 88 (45.4%) faculty and 106 (54.6%) trainees. Trainees were more likely to report a negative impact of the pandemic compared with faculty (75.5% vs. 50%, p < 0.01). Most respondents reported a decrease in formal educational activities (69.8%), inpatient (77.7%) and outpatient (77.8%) clinical teaching. Despite this, most perceived clinical and teaching skills to have stayed the same. Most (93.4%) participated in virtual education; however, only 36.5% of faculty taught virtually. Only 4.2% of faculty had extensive training in virtual teaching and 28.9% felt very comfortable teaching virtually. In the future, most (87.5%) prefer a hybrid approach, particularly virtual didactic conferences and virtual grand rounds. Faculty themes included challenges to workflows and increased empathy for trainees, while trainee themes included increased work/life balance and support, but increased burnout.

Conclusion

Many changes and innovations resulted from the pandemic. Hospital systems and GME programs should consider this data and incorporate viewpoints from trainees and faculty when adapting educational strategies in the future.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01737-8.

Measuring Training Disruptions Using an Informatics Based Tool

OBJECTIVE

Training disruptions, such as planned curricular adjustments or unplanned global pandemics, impact residency training in ways that are difficult to quantify. Informatics-based medical education tools can help measure these impacts. We tested the ability of a software platform driven by electronic health record data to quantify anticipated changes in trainee clinical experiences during the COVID-19 pandemic.

METHODS

We previously developed and validated the Trainee Individualized Learning System (TRAILS) to identify pediatric resident clinical experiences (i.e. shifts, resident provider-patient interactions (rPPIs), and diagnoses). We used TRAILS to perform a year-over-year analysis comparing pediatrics residents at a large academic children's hospital during March 15-June 15 in 2018 (Control #1), 2019 (Control #2), and 2020 (Exposure).

RESULTS

Residents in the exposure cohort had fewer shifts than those in both control cohorts (P < .05). rPPIs decreased an average of 43% across all PGY levels, with interns experiencing a 78% decrease in Continuity Clinic. Patient continuity decreased from 23% to 11%. rPPIs with common clinic and emergency department diagnoses decreased substantially during the exposure period.

CONCLUSIONS

Informatics tools like TRAILS may help program directors understand the impact of training disruptions on resident clinical experiences and target interventions to learners' needs and development.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce

OBJECTIVE

Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce.

METHODS

A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions.

RESULTS

Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact.

CONCLUSIONS

Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

Three Years of X + Y Scheduling: Longitudinal Assessment of Resident and Faculty Perceptions

OBJECTIVE

Five pediatric residency programs implemented true X + Y scheduling in 2018 where residents have continuity clinic in "blocks" rather than half-day per week experiences. We report the impact X + Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences over a 3-year timeframe.

METHODS

Electronic surveys were sent to residents and faculty of the participating programs prior to implementing X + Y scheduling and annually thereafter (2018-2021). Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotations. Data were analyzed using z-tests for proportion differences.

RESULTS

One hundred and eight six residents were sent the survey preimplementation and 254 to 289 postimplementation with response rates ranging from 47% to 69%. Three hundred and seventy-eight to 395 faculty members were sent the survey with response rates ranging from 26% to 51%. Statistically significant (P < .05) sustained perceived improvements over 3 years with X+Y were seen in outpatient continuity, inpatient workflow, and time for teaching both inpatient and in continuity clinic.

CONCLUSIONS

X + Y scheduling can lead to perceived improvements in various aspects of pediatric residency programs. Our study demonstrates these improvements have been sustained over 3 years in the participating programs.

The Impact of the COVID-19 Pandemic on Pediatric Graduate Medical Education: Lessons Learned and Pathways Forward

In this article, the authors describe the impact of the COVID-19 pandemic on pediatric graduate medical education (GME), including the impact on clinical experiences for trainees, teaching methods used, trainee wellness, GME leader wellness and support, and the traditional interview process. A thorough literature review was done to identify impacts of the COVID-19 pandemic on pediatric GME. In addition, information was collected through Association of Pediatric Program Directors virtual cafes and conferences. Positive changes for GME from the COVID-19 pandemic included: the rapid transition to telehealth; asynchronous learning allowing for increased cross-program collaboration; innovative online teaching modalities; increased flexibility and decreased cost of online recruitment; and shared innovations across pediatric GME. Challenging aspects of the COVID-19 pandemic included: decreased learning about common childhood illnesses, such as bronchiolitis, acute otitis media, and influenza; decreased patient volumes and patient complexity in clinics and inpatient wards, leading to less practice developing efficiency, time management, and triaging skills; and an increased burden on trainees, including moral distress and decreased support from one another and other social supports. The COVID-19 pandemic has highlighted important opportunities in U.S. educational systems. As medical educators move forward, it will be important to learn from these while mitigating the negative impacts.

COVID-19 Impact on Intern Exposure to Common Inpatient Diagnoses

OBJECTIVE

We sought to understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on the clinical exposure of pediatric interns to common pediatric inpatient diagnoses.

METHODS

We analyzed electronic medical record data to compare intern clinical exposure during the COVID-19 pandemic from June 2020 through February 2021 with the same academic blocks from 2017 to 2020. We attributed patients to each pediatric intern on the basis of notes written during their pediatric hospital medicine rotation to compare intern exposures with common inpatient diagnoses before and during the pandemic. We compared the median number of notes written per intern per block overall, as well as for each common inpatient diagnosis.

RESULTS

Median counts of notes written per intern per block were significantly reduced in the COVID-19 group compared with the pre-COVID-19 group (96 [interquartile range (IQR): 81-119)] vs 129 [IQR: 110-160]; P < .001). Median intern notes per block was lower in the COVID-19 group for all months except February 2021. Although the median number of notes for many common inpatient diagnoses was significantly reduced, they were higher for mental health (4 [IQR: 2-9] vs 2 [IQR: 1-6]; P < .001) and suicidality (4.5 [IQR: 2-8] vs 0 [IQR: 0-2]; P < .001). Median shifts worked per intern per block was also reduced in the COVID-19 group (22 [IQR: 21-23] vs 23 [IQR: 22-24]; P < .001).

CONCLUSIONS

Our findings reveal a significant reduction in resident exposure to many common inpatient pediatric diagnoses during the COVID-19 pandemic. Residency programs and pediatric hospitalist educators should consider curricular interventions to ensure adequate clinical exposure for residents affected by the pandemic.

Pediatric Resident Perspectives on the Impact of COVID-19 on Training

OBJECTIVES

At the onset of the coronavirus disease 2019 pandemic, disruptions to pediatric care and training were immediate and significant. We sought to understand the impact of the pandemic on residency training from the perspective of pediatric residents.

METHODS

We conducted a cross-sectional survey of categorical pediatric residents at US training programs at the end of the 2019-2020 academic year. This voluntary survey included questions that explored the impact of the coronavirus disease 2019 pandemic on resident training experiences, postresidency employment plans, and attitudes and perceptions. Data were analyzed by using descriptive statistics and mixed-effects regression models. We performed a sensitivity analysis using respondents from programs with a >40% response rate for questions regarding resident attitudes and perceptions.

RESULTS

Residents from 127 of 201 training programs (63.2%) completed the survey, with a response rate of 18.9% (1141 of 6032). Respondents reported multiple changes to their training experience including rotation schedule adjustments, clinic cancellations, and an increase in the use of telemedicine. Respondents also reported inconsistent access to personal protective equipment and increased involvement in the care of adult patients. Graduating resident respondents reported concerns related to employment. Respondents also noted a negative impact on their personal wellness.

CONCLUSIONS

Responding residents reported that nearly every aspect of their training was impacted by the pandemic. Describing their experiences may help residency program and hospital leaders supplement missed educational experiences, better support residents through the remaining months of the pandemic, and better prepare for extraordinary circumstances in the future.

Pediatric Residency Education During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had profound effects on society and, in particular, on many aspects of medical care. Residency training programs are often integral parts of our medical community and consequently have experienced changes in structure, format, and content. The conversion to virtual or online learning has been nearly universal. Decreases in common pediatric diagnoses such as respiratory syncytial virus and asthma have led to less first-hand experience for residents. Limitations designed to minimize the spread of COVID-19, such as use of personal protective equipment and group size limits, have led to fewer clinic rotations, fewer clinic sessions, and fewer patient experiences. Infections of residents themselves have led to an increase in back-up call system usage and a strain on staffing. Mandatory limits on group gatherings have also impaired camaraderie and the overall well-being of trainees. [Pediatr Ann. 2021;50(12):e509-e514.].