Validating objectives and training in Canadian paediatrics residency training programmes

Pearls of wisdom: Updated skill-specific parenting strategies in the first 6 years

This article provides knowledge translation on up-to-date parenting strategies (pearls of wisdom). These pearls support the development of specific skills in children from birth through 5 years of age. Paediatricians have indicated that they feel inadequately trained in providing parenting guidance. This article could be used by family physicians, community health nurses, nurse practitioners, and paediatricians as an office reference when providing anticipatory parenting guidance and when there are parent or clinician concerns that relate to various developmental stages. Included are general tips for guiding parents and pearls that support self-regulation, attachment, perspective taking, and developing the child's sense of self. The present review links pearls to specific reference sources in the literature which cite developmental standards and advice. Evidence-based parenting programs are cited for children with more complex presentations due to developmental, regulatory, or behavioural disorders, temperament individual differences, or limited parenting support. Website links for parents are recommended, and Parenting Pearls handouts provided, to solidify understanding and follow through.

Advanced neonatal procedural skills: a simulation-based workshop: impact and skill decay

BACKGROUND

Trainees aiming to specialize in Neonatal Perinatal Medicine (NPM), must be competent in a wide range of procedural skills as per the Royal College of Canada. While common neonatal procedures are frequent in daily clinical practice with opportunity to acquire competence, there are substantial gaps in the acquisition of advanced neonatal procedural skills. With the advent of competency by design into NPM training, simulation offers a unique opportunity to acquire, practice and teach potentially life-saving procedural skills. Little is known on the effect of simulation training on different areas of competence, and on skill decay.

METHODS

We designed a unique simulation-based 4-h workshop covering 6 advanced procedures chosen because of their rarity yet life-saving effect: chest tube insertion, defibrillation, exchange transfusion, intra-osseus (IO) access, ultrasound-guided paracentesis and pericardiocentesis. Direct observation of procedural skills (DOPS), self-perceived competence, comfort level and cognitive knowledge were measured before (1), directly after (2), for the same participants after 9-12 months (skill decay, 3), and directly after a second workshop (4) in a group of NPM and senior general pediatric volunteers.

RESULTS

The DOPS for all six procedures combined for 23 participants increased from 3.83 to 4.59. Steepest DOPS increase pre versus post first workshop were seen for Defibrillation and chest tube insertion. Skill decay was evident for all procedures with largest decrease for Exchange Transfusion, followed by Pericardiocentesis, Defibrillation and Chest Tube. Self-perceived competence, comfort and cognitive knowledge increased for all six procedures over the four time points. Exchange Transfusion stood out without DOPS increase, largest skill decay and minimal impact on self-assessed competence and comfort. All skills were judged as better by the preceptor, compared to self-assessments.

CONCLUSIONS

The simulation-based intervention advanced procedural skills day increased preceptor-assessed directly observed procedural skills for all skills examined, except exchange transfusion. Skill decay affected these skills after 9-12 months. Chest tube insertions and Defibrillations may benefit from reminder sessions, Pericardiocentesis may suffice by teaching once. Trainees' observed skills were better than their own assessment. The effect of a booster session was less than the first intervention, but the final scores were higher than pre-intervention.

TRIAL REGISTRATION

Not applicable, not a health care intervention.

Summative content analysis of the recommendations from Project ECHO Ontario Autism

Background

Practitioners report a lack of knowledge and confidence in treating autistic children, resulting in unmet healthcare needs. The Extension of Community Healthcare Outcomes (ECHO) Autism model addresses this through discussion of participant-generated cases, helping physicians provide best-practice care through co-created recommendations. Recommendations stemming from ECHO cases have yet to be characterized and may help guide the future care of autistic children. Our objective was to characterize and categorize case discussion recommendations from Project ECHO Ontario Autism to better identify gaps in clinician knowledge.

Methods

We conducted a summative content analysis of all ECHO Ontario Autism case recommendations to identify categories of recommendations and their frequencies. Two researchers independently coded recommendations from five ECHO cases to develop the coding guide. They then each independently coded all remaining cases and recommendations from three cycles of ECHO held between October 2018 to July 2021, meeting regularly with the ECHO lead to consolidate the codes. A recommendation could be identified with more than one code if it pertained to multiple aspects of autism care. Categories from the various codes were identified and the frequency of each code was calculated.

Results

Of the 422 recommendations stemming from 62 cases, we identified 55 codes across ten broad categories. Categories included accessing community resources (n = 224), referrals to allied health and other providers (n = 202), ongoing autism care (n = 169), co-occurring mental and physical health conditions (n = 168), resources and tools for further learning (n = 153), physician to provide education and coaching to families (n = 150), promoting parent and family wellness (n = 104), supporting community autism diagnosis (n = 97), promoting patient empowerment and autonomy (n = 87), and COVID-19 (n = 26).

Conclusion

This is the first time that recommendations from ECHO Autism have been characterized and grouped into categories. Our results show that advice for autism identification and management spans many different facets of community-based care. Specific attention should be paid to providing continued access to education about autism, streamlining referrals to allied health providers, and a greater focus on patient- and family-centered care. Physicians should have continued access to autism education to help fill knowledge gaps and to facilitate families' service navigation.

Updated evidence-based developmental attainments for children: First 6 years

An accurate and well-rounded understanding of child development is essential to optimize child functioning and health. The First Six Years Developmental Attainments chart empowers clinicians to give parenting guidance and to evaluate age-specific developmental attainment of their pediatric patients. A practical knowledge translation tool, the chart integrates a comprehensive array of developmental skill attainments, citing the range of sources from classic to current literature. It includes definitions, explanations, and examples for skills, attainment age range, percentile, and oldest age of attainment where available so that the reader can ‘estimate the age’ for a child’s skills in each developmental sector. Sub-headings focus the clinician’s search for skills. This updated office reference is of critical use when clinicians guide parents with strategies suited to the child’s level of developmental skills. With levels of evidence described, this clinical tool could be used for future national or international studies to develop strategies most useful for clinicians, trainees of different levels, and parents supporting child development.

Assessing nephrology competence in general paediatrics—A survey of general paediatricians, paediatric nephrologists, residents, and program directors

Objective

The objective of this study was to identify nephrology topics of lowest perceived competency and importance for general paediatricians.

Methods

Surveys were distributed to general paediatricians, paediatric residents, paediatric residency program directors, and paediatric nephrologists. Perceived importance and competence were rated on a 5-point Likert scale. Means and 95% confidence intervals were calculated.

Results

Mean perceived competency from general paediatricians across all nephrology domains was 3.0, 95%CI (2.9 to 3.1) and mean importance was 3.2, 95%CI (3.1 to 3.3). Domains scoring below the means for competence and importance, respectively were kidney stones (2.5, 95%CI [2.2 to 2.7]) and 2.6, 95%CI [2.3 to 2.8]), acute kidney injury (2.5, 95%CI [2.2 to 2.8] and 2.4, 95%CI [2.1 to 2.8]), chronic kidney disease (1.9, 95%CI [1.7 to 2.2] and 2.1, 95%CI [1.8 to 2.4]), tubular disorders (1.8, 95%CI [1.6 to 2.0] and 2.0, 95%CI [1.8 to 2.3]), and kidney transplant (1.6, 95%CI [1.4 to 1.8] and 1.7, 95%CI [1.4 to 1.9]). Residents, program directors, and paediatric nephrologists agreed that stones, chronic kidney disease, tubular disorders, and transplant were of lower importance. However, acute kidney injury was the domain with the largest discrepancy in perceived importance between residents (4.4, 95%CI [4.2 to 4.6]), nephrologists (4.2, 95%CI [3.8 to 4.6]), and program directors (4.2, 95%CI [3.7 to 4.7]) compared to general paediatricians ([2.4, 95%CI [2.1 to 2.8]; P<0.05).

Conclusion

Paediatricians did not believe acute kidney injury was important to their practice, despite expert opinion and evidence of long-term consequences. Educational interventions must address deficits in crucial domains of renal health in paediatrics.

Preparedness to practice paediatric hospital medicine

Background

The field of paediatric hospital medicine (PHM) is evolving to meet the needs of an increasingly complex paediatric population, lead quality improvement initiatives, and conduct field-specific teaching and research. Over 50 subspecialty PHM fellowship programs exist in the USA and Canada and more are under active development to ensure trainees are prepared to perform competencies specific to the field following transition to independent practice.

Objective

The objective of this study was to assess the perceived preparedness of recently graduated general paediatric residents and recently certified staff paediatricians in Canada with respect to the practice of PHM.

Methods

A survey based on the 'Objectives of Training in Pediatrics' of the Royal College of Physicians and Surgeons of Canada (RCPSC) was distributed to graduating paediatric residents and recently graduated staff paediatricians (2013 to 2017) practicing in the hospital setting. Qualitative comments were also obtained.

Results

Fifty-five surveys were completed (50%). Respondents perceived that, at the on-set of starting practice, they would require assistance or consultation with the majority of representative PHM task competencies. Differences in perception between the two groups were minimal. Our study identified sub-sets of perceived areas of particular strengths (Professional) and deficiencies (Medical Expert, Manager, and Scholar).

Conclusions

Results may help inform future curricula for general paediatric residency programs and provide insight into competencies that may be better targeted for PHM fellowship training programs. This study may also stimulate discussion regarding entrustable professional activities for paediatric curricula as the medical community shifts to a new paradigm of outcome-based assessment.

Anticipatory guidance for behaviour concerns: School age children

Parenting powerfully influences children's cognitive and social-emotional development. Parents often have behaviour concerns and seek advice from their clinician. This paper is an evidence-based clinic tool to empower clinicians to promote pro-social behaviour through developmentally-targeted strategies that parents can use to decrease problem behaviour. Typical scenarios are provided for noncompliance, aggression, attention, and bedtime worries.

Parenting principles

Authoritative parenting is essential for healthy outcomes. It combines warmth and structure to foster emotional regulation, attachment, and perspective-taking and problem-solving skills.

A framework for developmentally-targeted parenting strategies

We present a framework for parenting strategies which integrates The Incredible Years Parenting Pyramid® and Antecedent-Behaviour-Consequence model, to guide parents on prevention of problem behaviour. The framework emphasizes daily relationship time and using empathy to the child to help him/her calm, become aware of his/her own emotions, and be receptive to the parent's instructions. It also teaches skills to replace the behaviour, providing physical needs, and explaining reasons for rules. When parents focus most of their time on the foundational skills of the pyramid, problem behaviour decreases, and consequences are rarely needed.

Managing behaviour concerns

Managing behaviour concerns also requires screening for developmental and behavioural disorders, and following up to determine whether referrals are needed.

Conclusion

Anticipatory guidance for behaviour concerns prioritizes children's rights to respect and dignity.

Program directors' perceptions of importance of pediatric procedural skills and resident preparedness

Background

The Royal College of Physicians and Surgeons of Canada (RCPSC) objectives for training in pediatrics include 26 procedural skills, 11 of which are included in the final in-training evaluation report (FITER). The importance of each procedure for practice and the preparedness of pediatric residency graduates to perform these procedures are not known.

Methods

A questionnaire was distributed to all pediatric residency program directors and members of the RCPSC Specialty Committee in Pediatrics (N = 21) in October 2010, requesting them to rate the perceived importance and preparedness of graduating pediatric residents in all procedural skills on a 5 point Likert scale, as well as the presence of a curriculum and documentation for each procedure. Mean importance and preparedness were calculated for each procedure.

Results

Response rate was 16/21 (76 %). Perceived preparedness was significantly lower than importance for the majority of procedures (p < 0.05). Ten procedures had a high mean importance rating (>3) but a low mean preparedness rating (<3). Presence of a curriculum and documentation for procedures varied across centers, and their presence was correlated with both perceived importance and preparedness (p < 0.0001).

Conclusions

Many procedures in which pediatric residents are required to be competent by the RCPSC are felt to be important. Residents are not felt to be adequately prepared in several of the required procedures by the time of graduation. Procedures with high ratings of importance but low preparedness ratings should be targeted for curricular interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1499-8) contains supplementary material, which is available to authorized users.

Procedural skills in paediatric residency: Re-evaluating the competencies

BACKGROUND

The Royal College of Physicians and Surgeons of Canada (RCPSC) sets objectives for residency training, including many skills that may not be commonly performed in practice.

OBJECTIVE

To describe attitudes of residents enrolled in Canadian paediatric residency programs toward procedural skills training, including perception of importance and perceived proficiency of the RCPSC-required procedures.

METHODS

An anonymous electronic survey was distributed to all senior residents enrolled in Canadian paediatric residencies, using a five-point Likert scale to address procedural importance and corresponding proficiency. Data were analyzed using descriptive statistics, with Pearson correlation coefficients used to describe relationships among variables.

RESULTS

A total of 68 residents responded. Fifteen skills had a mean importance ≥4 (very or extremely important) and five skills had a mean rating <3 (somewhat or not important). Residents believed they were extremely or very proficient (mean rating ≥4) for three skills (bag-mask ventilation, lumbar puncture and chest x-ray interpretation). They reported 23 procedures for which they felt somewhat to not proficient (mean <3). The correlation between importance and proficiency was high (Pearson's correlation coefficient = 0.87). However, proficiency was significantly lower than importance (P<0.05) for the majority of procedures (88%). The largest gaps between importance and proficiency were observed for chest tube insertion, gathering evidence of child maltreatment, defibrillation and intraosseous insertion.

CONCLUSION

Many, but not all, RCPSC-required procedures are believed to be important. Residents do not believe that they are adequately proficient in many of these procedures. Skills with the greatest gap between importance and proficiency may be targets for curricular interventions.

Development and validation of a self-efficacy scale for clinical decision-making in general paediatrics

BACKGROUND

Success in a task is not only related to skill, but it is also related to 'self-efficacy', or belief in one's capability to perform that task. No tool currently exists to measure self-efficacy in clinical decision-making in general paediatrics.

OBJECTIVE

To develop and provide validity evidence for the General Pediatrics-specific Self-Efficacy (GPedsSE) scale.

METHODS

The five-item GPedsSE scale, developed using an expert panel, was matched to the New General Self-Efficacy (NGSE) scale's structure for validity analysis purposes. Thirty-six postgraduate year 1 to postgraduate year 5 paediatric residents of the Montreal Children's Hospital (Montreal, Quebec) completed the GPedsSE and NGSE scales, with items interspersed.

RESULTS

The mean (± SD) GPedsSE score was 18.6±2.6 of 25. Total GPedsSE and NGSE scores were moderately correlated (r=0.54, P<0.005). On planned comparison, the GPedsSE score increased with training year (F[1.3]=6.62; P<0.001), while the NGSE score did not (F<0.37). Exploratory factor analysis showed two components, each aligning with a scale.

CONCLUSION

The GPedsSE scale contextualizes an existing tool to general paediatrics, a novel concurrent validity approach.

Entrustable professional activities in family medicine

BACKGROUND

The Accreditation Council for Graduate Medical Education Outcome Project intended to move residency education toward assessing and documenting resident competence in 6 dimensions of performance important to the practice of medicine. Although the project defined a set of general attributes of a good physician, it did not define the actual activities that a competent physician performs in practice in the given specialty. These descriptions have been called entrustable professional activities (EPAs).

OBJECTIVE

We sought to develop a list of EPAs for ambulatory practice in family medicine to guide curriculum development and resident assessment.

METHODS

We developed an initial list of EPAs over the course of 3 years, and we refined it further by obtaining the opinion of experts using a Delphi Process. The experts participating in this study were recruited from 2 groups of family medicine leaders: organizers and participants in the Preparing the Personal Physician for Practice initiative, and members of the Society of Teachers of Family Medicine Task Force on Competency Assessment. The experts participated in 2 rounds of anonymous, Internet-based surveys.

RESULTS

A total of 22 experts participated, and 21 experts participated in both rounds of the Delphi Process. The Delphi Process reduced the number of competency areas from 91 to 76 areas, with 3 additional competency areas added in round 1.

CONCLUSIONS

This list of EPAs developed through our Delphi process can be used as a starting point for family medicine residency programs interested in moving toward a competency-based approach to resident education and assessment.

Review article: closing the research gap at the interface of learning and clinical practice

PURPOSE

The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation.

PRINCIPAL FINDINGS

Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a "research gap" where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively.

CONCLUSION

Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.