Improved tracheostomy-dependent patient outcomes after implementation of the Pediatric Resident Education in Pulmonary (PREP) Boot Camp

INTRODUCTION

Children with tracheostomies are high risk for morbidity and mortality. Pediatric resident physicians are not routinely taught skills to care for this vulnerable patient population. Few reports link educational interventions to improved patient outcomes. This study evaluates the impact of an intensive educational training program on pediatric residents' observed skills and tracheostomy-dependent patient outcomes.

METHODS

Pediatric post-graduate year 2 (PGY2) resident physicians rotating through the inpatient pediatric pulmonology month at Children's Hospital Colorado July 2018-2019 participated in the Pediatric Resident Education in Pulmonary (PREP) Boot Camp, an intensive educational program with an interactive lecture and simulation experience on patients with tracheostomy-dependence. PGY2s who partook in PREP and PGY3s who rotated before PREP initiation were invited to be studied. Primary outcomes included: (1) resident skills assessed by direct observation during simulation encounters and (2) rates of intensive care unit (ICU) transfers in tracheostomy-dependent patients following acute events before and after introduction of PREP. We hypothesized that increased education would enhance resident skills and improve patient outcomes by decreasing the rate of ICU transfers.

RESULTS

PGY2 residents retained skills learned during PREP up to 11 months following initial participation, and significantly outperformed their PGY3 counterparts. There was a significant decrease in ICU transfer rate in patients with tracheostomies admitted to the pulmonary team during the 19 months following initiation of PREP.

CONCLUSIONS

Enhanced early education may improve resident physicians' ability to care for complex patients with tracheostomies and could improve outcomes in this high-risk population.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students

INTRODUCTION

Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment.

METHODS

This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations.

RESULTS

Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment.

DISCUSSION

Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

A Narrative Review of Key Studies in Medical Education in 2022: Applying the Current Literature to Educational Practice and Scholarship

The expectation of every academic pediatrician is to stay updated on current evidence in their field; this is especially true of pediatric clinician educators who are training the next generation of pediatricians. Since 2016, select members of the Academic Pediatric Association Education Committee have curated educational research articles in order to distill the increasing volume of research related to medical education. The purpose of this narrative review is to summarize 14 articles published in 2022 related to medical education that may impact the work of pediatric clinician educators and educational leadership. These articles are organized into 6 overarching domains: selection and recruitment, promoting learner growth and development, learning environment and wellness, curriculum development, assessment, and educator development.

A Narrative Review of Key Studies in Medical Education in 2021: Applying Current Literature to Educational Practice and Scholarship

To remain at the forefront of clinical practice and pedagogy, pediatric medical educators must stay informed of the latest research. Yet familiarization with the growing body of literature in both pediatrics and medical education is a near-impossible task for the busy medical educator. The purpose of this annotated bibliography is to summarize key manuscripts in medical education published in 2021 that have the potential to significantly influence a pediatric medical educator's practice. Using a 2-staged iterative process, discrete author pairs reviewed 1599 abstracts from 16 medical education and specialty journals. In summary, 16 manuscripts were selected and grouped into the following 6 domains: assessment and feedback, USMLE Step 1 changes, communication, wellness, diversity and inclusion, and professional development. The authors provide abridged summaries and high-yield take-aways from these manuscripts that may impact educational practices in pediatrics. This year, we also provide a 6-year retrospective review of the journals that have had selected articles for this annotated bibliography since inception.

An Annotated Bibliography of Key Studies in Medical Education in 2020: Applying the Current Literature to Educational Practice and Scholarship

Pediatric medical educators, with their multitude of responsibilities, may have difficulty staying abreast with both medical education and specialty specific medical literature. The body of medical literature is growing at an exponential rate. This annotated bibliography serves as a summary of highlighted medical education literature in the year 2020. The purpose was to identify manuscripts which have the potential to significantly influence a pediatric medical educator's practice. The authors reviewed abstracts from 14 medical education and specialty journals using a two-staged review process. Each stage of review was completed by 2 different authors. A total of 1861 abstracts were reviewed and ultimately 15 key manuscripts were identified. The authors grouped the manuscripts into 6 core domains: diversity and inclusion, faculty development, feedback, learner development, mentorship, and teaching skills. Condensed summaries of each medical education manuscript likely to influence educational practice are provided by the authors in this annotated bibliography.

Describing Overarching Curricular Goals for Individualized Education

Phenomenon: The phenomenon of individualized education, an essential component of competency-based medical education, addresses individual learner needs while working toward standardized learning outcomes. One challenge with broadly implementing individualized education is the lack of a pragmatic operational definition. To formalize expectations for individualized education, the Accreditation Council of Graduate Medical Education in 2013 began requiring six months of individualized curriculum (IC) during pediatric residency; however, there is not a national standard of formal curricular goals for the IC as an educational entity. Examining and describing the overarching curricular goals of IC could provide a framework for discourse about and further study of individualized education in medicine across disciplines and the continuum of medical education. Thus, we aimed to describe the phenomenon of individualized education through the lens of the goals of the IC in pediatric residency in the United States. Approach: In 2017, a purposeful sample of Pediatric Residency leaders were recruited to represent a diverse sample of program sizes, regions of the country, and importance of the IC to the program leadership. They completed an online survey with open-ended questions describing formal and implicit goals of their program's IC. The authors analyzed responses initially using conventional content analysis, then investigated whether the themes for program goals aligned with any existing educational theory. The concepts and language aligned with the principles of self-determination theory (SDT); therefore, the IC goals were subsequently grouped using the SDT domains of relatedness, autonomy, and competence. A focus group with a subset of survey respondents was conducted for member checking and elaboration of concepts. Findings: Program leaders from a diverse sample of 36 programs participated in the survey and a subset of 11 programs participated in the focus group. The common goals across all programs are listed in parentheses and organized by domains of SDT: 1)Relatedness goals (engage in mentorship, select a career) cultivate resident's professional identity based on their desired future career path; 2)autonomy goals (create a learning plan, practice accountability) help residents plan their path; and fulfillment of their plans lead to 3)competence goals (develop targeted clinical skills and knowledge, ensure comprehensive exposure, address learning gaps), ensuring they have a comprehensive skill set for their chosen identity. Insights: This study provides a framework to describe the phenomenon of individualized education through the lens of IC curricular goals in pediatric residency. The goals for IC that emerged from this study serve as a pragmatic framework for implementation of individualized education. They provide a common language and structure to promote more rigorous and collaborative study of individualized education across programs, disciplines, and settings in medicine. They may function as a roadmap for learners to navigate educational activities and for programs to help shape the experiences of their learners and examine outcomes of individualized education in their programs. The framework can also help individual pediatric residency programs structure improvements to their IC. Disciplines beyond pediatrics may also use this framework to better structure elective experiences to capitalize on the benefits of individual education.

An Annotated Bibliography of Key Studies in Medical Education in 2019: Applying the Current Literature to Educational Practice and Scholarship

Pediatric medical educators have the dual challenge of remaining up-to-date in the field of pediatrics and in the field of medical education. Due to the volume of information published in these 2 fields it can be nearly impossible to remain current in both fields of practice. To facilitate interpretation of the most recent medical education research, the authors conducted an annotated bibliography of medical education literature published in 2019. The purpose of this annotated bibliography was to identify manuscripts which had the potential to significantly influence a pediatric educator's practice. Using a 2-staged review process, the authors reviewed abstracts from 13 medical education and specialty journals. All reviews were independently completed by 2 different reviewers for each journal in both stages. A total of 4700 abstracts were reviewed and 17 key manuscripts were identified. The authors grouped the key manuscripts into 6 core themes: bedside teaching, learning climate, bias, learner autonomy, learner in trouble, and resident competency. This annotated bibliography provides the authors' condensed summary of the medical education manuscripts most likely to influence educational practices for the busy pediatric medical educator.

The COVID-19 Pandemic as an Imperative to Advance Medical Student Assessment: Three Areas for Change

Conditions caused by the COVID-19 pandemic have disrupted clinical practice and all aspects of medical education. Yet the need to continue to train physicians to care for patients and communities is greater than ever. Medical educators are responding by adapting curricula in response to requirements for social distancing, changing availability of clinical learning opportunities, and limitations on testing center availability for examinations. These disruptions require a systems approach to ensure that learners achieve competence in preparation for advancement in training toward unsupervised practice. In this article, the authors assert that medical educators, obligated by current conditions to adapt educational experiences, should seize the opportunity presented by the pandemic to make needed changes in 3 areas aligned with competency-based medical education: focusing on outcomes, broadening the assessment toolbox, and improving the undergraduate medical education-to-graduate medical education (UME-to-GME) transition. Defined outcomes, as exemplified by entrustable professional activities, will enable curricular designers to shorten and adapt learning experiences by focusing on students' achievement of prespecified learning outcomes. Broadening the assessment toolbox entails capturing more and different assessment information about learners to provide a well-rounded view of their strengths and areas for growth in both traditional and novel settings, such as telehealth. Limitations on available data, such as licensing examination scores and clerkship grades, heighten the urgency to revise the system for the UME-to-GME transition by enhancing the quality and usability of information available to residency program directors. Educators should capitalize on the opportunity presented by altered conditions due to the COVID-19 pandemic to make these needed changes to the educational system, to prepare physicians to provide health care and lead the health care system into the future.

Pediatric Resident Education in Pulmonary (PREP): A Subspecialty Preparatory Boot Camp Curriculum for Pediatric Residents

INTRODUCTION

Medical errors can occur any time resident physicians transition between rotations, especially to unfamiliar areas such as subspecialty pediatrics. To combat this, we created and implemented the pediatric resident education in pulmonary (PREP) boot camp using Kern's six-step approach to curriculum development.

METHODS

PREP was a 5-hour session with multiple high-yield components held on the first day of each new rotation, aimed to prepare residents to care for complex pulmonary inpatients, including those with tracheostomy and ventilator dependence, asthma, and cystic fibrosis. The curriculum was evaluated at multiple time points through surveys of residents and faculty and two formal resident focus group sessions.

RESULTS

PREP was successfully implemented in July 2018 with continued monthly sessions held. Thirty-five residents participated in the first year. Resident perceived preparedness and confidence in taking call duties increased significantly following PREP. All residents rated PREP as extremely helpful or very helpful, the highest ratings possible. Overall, residents preferred active learning strategies. All qualitative data revealed positive effects of PREP. Clinical faculty in the pulmonology division found PREP similarly helpful and felt that PREP better prepared residents to provide care to pulmonary inpatients than our previous model.

DISCUSSION

Our monthly preparatory boot camp on the first day of residents' inpatient pulmonary rotation has improved resident experience, preparedness, and ability to care for complex pulmonary patients. The curriculum was adjusted in response to feedback to increase hands-on time and interactive sessions. Protected time for residents and active learning strategies were key to success of PREP.

"When in Doubt, Change It out": A Case-Based Simulation for Pediatric Residents Caring for Hospitalized Tracheostomy-Dependent Children

INTRODUCTION

Caring for technology-dependent children, such as those with tracheostomy and ventilator dependence, can be new and frightening for pediatric residents. Education about emergencies in this patient population is important because these children are at risk for in-hospital complications. Safe care of the tracheostomy-dependent child requires the ability to recognize common complications, such as tracheostomy tube obstruction or decannulation, and intervene appropriately by suctioning and/or replacing the tracheostomy tube. This simulation-based curriculum teaches learners to identify and practice the management of these tracheostomy tube complications through low-fidelity simulation exercises.

METHODS

We created a simulation session with three cases reflecting in-hospital scenarios encountered by resident physicians caring for tracheostomy-dependent children in the inpatient setting. The simulation scenario, simulation environment preparation, materials list, and debriefing outline are provided for the instructor for each simulation case. Validity evidence for the assessment tool was obtained by calculating the interrater reliability of two different raters. Resident feedback was obtained through anonymous surveys.

RESULTS

Twelve pediatric senior residents completed the experience. It received overwhelmingly positive feedback on learner evaluation forms, with 90% finding the experience very or extremely helpful. The intraclass correlation coefficient of interrater reliability for our assessment tool was 0.93.

DISCUSSION

The simulation was well received by residents. The interrater reliability was acceptable. This low-fidelity simulation exercise can easily be executed with minimal materials or instructor training. High-yield, just-in-time training with postcase debriefing is key to the simulation's success.

Identification of foundational non-clinical attributes necessary for successful transition to residency: a modified Delphi study with experienced medical educators

BACKGROUND

We aimed to identify foundational non-clinical attributes expected of medical school graduates to be successful in residency.

METHODS

We conducted a three-round modified Delphi study with snowball sampling of experienced medical educators. In Round 1, respondents rated 28 attributes identified from a literature search. Additional attributes were proposed through invited comments. In Round 2, respondents expressed their agreement with advanced attribute definitions and examples. Consensus on final definitions and examples was obtained in Round 3.

RESULTS

Sixty-four percent (105/163) of invited educators participated in Round 1. There was broad representation of educational focus (undergraduate, graduate, and continuing medical education) and field of practice (primary care, sub-specialty, medical, and surgical). Thirteen attributes were advanced to Round 2. Ninety-seven of 105 (92%) respondents participated in Round 2, with greater than 92% agreement for all attributes. Three pairs were consolidated. In Round 3, 88% (85/97) of educators expressed greater than 92% agreement about definitions and representative examples. The final 10 foundational attributes are: communication skills, critical thinking, emotional intelligence, ethical behavior, intellectual curiosity, organizational skills, resilience, self-improvement, teamwork, and vocational commitment.

CONCLUSION

Through a consensus-building process of medical educators, we identified and defined 10 foundational non-clinical attributes for a medical student's successful transition to residency.

In Pursuit of Meaningful Use of Learning Goals in Residency: A Qualitative Study of Pediatric Residents

PURPOSE

Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency.

METHOD

Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory.

RESULTS

Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through.

CONCLUSIONS

Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Using Individualized Learning Plans to Facilitate Learner-Centered Teaching

Individualized learning plans (ILPs) are helpful tools that can facilitate learner-centered education and can be used with all levels of learners. We introduce the concept of ILPs, the rationale for their use in pediatric and adolescent gynecology education, and review the challenges that learners might face in creating ILPs, and describes how educators can support learners during this process.

Applying the one minute preceptor model to pediatric and adolescent gynecology education

There are multiple challenges to teaching in the clinical setting. The One Minute Preceptor is a learner-centered model for effective and efficient teaching in a clinical setting that can help to overcome these challenges. It consists of 5 microskills: get a commitment; probe for supporting evidence; teach general rules; reinforce what was right; correct mistakes. This article illustrates with case vignettes the use of these microskills for the busy Pediatric and Adolescent Gynecology clinician.

Students' perspectives on the fourth year of medical school: a mixed-methods analysis

PURPOSE

Little is known about the purpose and value of the fourth year of medical school from the perspective of medical students. In this study, the authors systematically explored the year's purpose and value as determined by students.

METHOD

In April 2011, the authors conducted semistructured focus groups with graduating fourth-year students at the University of Colorado School of Medicine to understand their perspectives on the purpose of the fourth year. Using results of a thematic analysis of the focus group data, the authors developed and administered a 10-item questionnaire to all graduating fourth-year medical students in May 2011. Questionnaire data were analyzed using descriptive statistics and exploratory factor analysis.

RESULTS

A total of 17 students participated in two focus groups. Six themes related to the purpose of the fourth year emerged from the focus group data: career development and preparation, pursuing personal interests, career identification, exploration of diverse practice settings, influence of emotion, and flexibility and individualization. The questionnaire was completed by 134 of 148 students (91% response rate). Factor analysis of the questionnaire data identified five factors: strengthening one's residency application, developing skills, pursuing personal interests, exploring diverse practice settings, and identifying a career.

CONCLUSIONS

Medical students uniformly identified the fourth year of medical school as having purpose and value, but their views on the fourth year's purpose differed. This finding underscores the importance of the individualization of the fourth year. Students' perspectives should inform any decisions made about modifying fourth-year curricula and structure.

Assessing residents' written learning goals and goal writing skill: validity evidence for the learning goal scoring rubric

PURPOSE

To provide validity evidence for use of the Learning Goal Scoring Rubric to assess the quality of written learning goals and residents' goal writing skills.

METHOD

This two-part study used the rubric to assess University of Colorado third-year pediatric residents' written learning goals to obtain validity evidence. In study 1, five raters independently scored 48 goals written in 2010-2011 and 2011-2012 by 48 residents, who also responded to the Jefferson Scale of Physician Lifelong Learning (JeffSPLL). In study 2, two raters independently scored 48 goals written in 2011-2012 by 12 residents. Intraclass correlation coefficients (ICCs) assessed rater agreement to provide evidence for response process. Generalizability theory assessed internal structure. Independent-samples Mann-Whitney U tests and correlations assessed relationship to other variables. Content was matched to published literature and instructional methods.

RESULTS

The ICC was 0.71 for the overall rubric. In study 1, where the generalizability study's (G study's) object of measurement was learning goals, the phi coefficient was 0.867. In study 2, where the G study's object of measurement was the resident (goal writing skill), the phi coefficient was 0.751. The total mean score of residents with goal writing training was significantly higher than that of those without (7.54 versus 4.98, P < .001). Correlation between goal quality and JeffSPLL score was not significant. Investigators agreed that the content matched the published literature and instructional methods.

CONCLUSIONS

Preliminary validity evidence indicates that this scoring rubric can assess learning goal quality and goal writing skill.

Resident perceptions of autonomy in a complex tertiary care environment improve when supervised by hospitalists

BACKGROUND AND OBJECTIVE

Increasingly, academic hospitals have adopted hospitalist-based systems of inpatient pediatric care. Some studies comparing hospitalists with other attending physicians have suggested trainees are more satisfied with education from hospitalists. However, there are published concerns that the increased presence of hospitalists may reduce residents' autonomy. The objective of the current study was to evaluate pediatric residents' perceptions of their own autonomy after a broad ward restructuring to hospitalist-led teams.

METHODS

We analyzed data from standardized attending evaluations before and after a pediatric ward restructuring at an academic tertiary care hospital. Provision of most inpatient pediatric care changed from subspecialist-led teams to hospitalist-led teams. Numerical scores from evaluations before and after the restructuring were compared quantitatively. Comments from the evaluations were analyzed qualitatively to identify key themes.

RESULTS

Before the restructuring, there were 65 evaluations of 5 hospitalists and 602 evaluations of 32 subspecialists. After the restructuring, there were 188 evaluations of 8 hospitalists. Hospitalists were rated significantly higher on all teaching attributes compared with all attending physicians before the restructuring. The attending role in promoting autonomy was mentioned infrequently and reflected residents' perceived lack of autonomy before the restructuring. The primary theme after the restructuring was autonomy, specifically emphasizing resident leadership and decision-making and the appropriate balance of resident autonomy and supervision.

CONCLUSIONS

Although patient complexity was unchanged, a comparison of numerical ratings and resident comments before and after the restructuring indicates that hospitalists lead teams differently from subspecialists, with more emphasis on resident decision-making and autonomy.

Becoming an academic doctor: perceptions of scholarly careers

OBJECTIVES

Despite a recognised need to prepare future faculty members, little research has been conducted on how best to accomplish this task, especially among learners and faculty members within research-intensive medical schools.

METHODS

We interviewed 40 medical students, residents and faculty members from a single institution in the USA and asked questions about which careers the school does and should prepare individuals for, and the strengths of the institution for doing so. Interviews were conducted in person at a location chosen by the participant. All interviews were transcribed and coded using qualitative methods and software. The coding and themes were reviewed and discussed among members of the research team and verified by external reviewers.

RESULTS

We identified five themes related to becoming an academic doctor: early exposure to research; role models and mentoring; career pathways; interplay of personal and social factors, and career support for junior faculty members.

CONCLUSIONS

Results suggest that opportunities should be structured within undergraduate and graduate medical education to stimulate interest in careers as academic doctors and to aid junior faculty members to act as role models who can encourage learners to pursue careers in academic medicine.

Understanding the experience of being taught by peers: the value of social and cognitive congruence

BACKGROUND

Medical schools use supplemental peer-teaching programs even though there is little research on students' actual experiences with this form of instruction.

PURPOSE

To understand the student experience of being taught by peers instead of by faculty.

METHODS

We conducted focus groups with first- and second-year medical students participating in a supplemental peer-teaching program at one institution. From the learner focus group themes, we developed a questionnaire and surveyed all first-year students.

RESULTS

Focus groups revealed four learner themes: learning from near-peers, exposure to second-year students, need for review and synthesis, teaching modalities and for the peer-teachers, the theme of benefits for the teacher. Factor analysis of the survey responses resulted in three factors: second-year students as teachers, the benefit of peer-teachers instead of faculty, and the peer-teaching process. Scores on these factors correlated with attendance in the peer-teaching program (P < .05).

CONCLUSIONS

Students valued learning from near-peers because of their recent experience with the materials and their ability to understand the students' struggles in medical school. Students with the highest participation in the program valued the unique aspects of this kind of teaching most. Areas for improvement for this program were identified.