OBJECTIVE: Limitations on resident duty hours require formal education programs to be high-yield and impactful. Hospital medicine (HM) topics provide the foundation for inpatient pediatric knowledge pertinent to pediatric residents and medical students. Our primary objective was to describe the creation of an innovative pediatric HM curriculum designed to increase learners’ medical knowledge and their confidence in communicating with patients and families about these topics; our secondary objective was to evaluate the level of innovation of the conference sessions perceived by the learners.
METHODS: A systematic approach was used to develop a curriculum framework incorporating a variety of interactive and engaging educational strategies. Six sessions were studied over the 2012–2013 academic year. The bimonthly sessions were presented during the resident daily conference schedule as a recurring pediatric HM series. Change in learners’ medical knowledge and confidence in communicating with families were analyzed presession to postsession by using McNemar’s test and the Wilcoxon signed rank test, respectively. Learners rated the level of innovation for each session on a 5-point Likert scale.
RESULTS: Content covered during the 6 sessions included bronchiolitis, child abuse, health care systems, meningitis/fever, urinary tract infection, and wheezing. Medical knowledge increased presession to postsession (P < .001), as did confidence in communicating about each topic with families (P < .01). The average rating score for all sessions was highly innovative.
CONCLUSIONS: A systematic approach is useful for developing new curricula for pediatric learners. Focusing on high-yield topics and established competencies allows impactful education sessions within the confines of pediatric learners’ schedule constraints.
As the health care system in the United States evolves, educators are challenged to maximize learning opportunities with high-impact and practical strategies. The advent of the Accreditation Council for Graduate Medical Education resident duty hour restrictions in July 20111 challenged the traditional educational environment for pediatric learners nationwide. With concern for the educational effects of constraints placed on time spent by physician trainees in the hospital,2 considerable efforts should be dedicated to adapting resident education endeavors and approaches.3 To maximize teaching time in a way that appeals to today’s self-directed4,5 and technology-savvy medical learners, it is necessary to transform allotted conference time from the traditional lecture-based model that focuses on basic acquisition of facts and passive learning to interactive sessions that allow for active application of knowledge and skills.
The task of creatively teaching residents and medical students foundational general inpatient pediatric topics is important for hospitalist educators to consider. As the field of pediatric hospital medicine (HM) grows, the key role of pediatric hospitalists in teaching medical learners has been well recognized.6–10 In 2010, a group of hospitalists published the Pediatric Hospital Medicine Core Competencies, a comprehensive list of topics pertinent to caring for inpatient pediatrics patients11,12 that provides a framework to aid in the design of curricula aimed at teaching these important topics to pediatric learners.
At our hospital, HM faculty provide the majority of the inpatient general pediatric training to pediatric residents and medical students while rotating on our teams on the wards; however, a formal HM education program was not in place. Our primary objective was to systematically develop and implement an innovative HM resident education series to improve learners’ medical knowledge and their ability to communicate about inpatient topics with patients and families. Our secondary objective was to evaluate the level of innovation of the new curriculum, as perceived by our learners.
Setting and Participants
A curriculum development methods and a paired pre–post survey study design were used to create and evaluate a new HM education series. The study was conducted at Cincinnati Children’s Hospital Medical Center, a large academic pediatric tertiary care center. This study was deemed exempt from oversight by the institutional review board.
The center’s Division of Hospital Medicine includes >40 faculty members and 6 academic fellows. The residency program has >180 residents, including categorical pediatric residents and those in combined programs. Approximately 20 medical students rotate through the inpatient ward teams each month as part of their pediatric clerkship. Residents and medical students attend a daily 0.5-hour morning report and a 1-hour noon conference on weekdays. Attendance at individual sessions is dependent on rotation schedule; ∼50 learners are present at most sessions.
Curriculum Design and Educational Intervention
To create the HM curriculum, a systematic curriculum development method was used,13 comprising problem identification, a needs assessment with learners, the creation of goals and objectives, educational strategy creation for each topic, and an implementation plan; this method is summarized in Table 1. Using this strategy, 6 pilot modules were first created that were presented in the 2011–2012 academic year as noon conference sessions, which included the following 6 topics: asthma, communication, evidence-based medicine application, fever of uncertain source, gastroenteritis, and Kawasaki disease. The pilot sessions were designed for feasibility and were not analyzed. Six more modules were then created for study, which were each presented once over the course of the conference schedule in the 2012–2013 academic year. These sessions focused on communicating effectively with patients and families, and they included the following topics: bronchiolitis, child abuse, health care systems, meningitis/fever, urinary tract infection, and wheezing.
The educational sessions were internally developed by the authors using various resources (textbooks, review articles, published literature, and institutional and national guidelines); input from local experts was also included in some sessions. Each session used presentation slides as a framework for discussion and incorporated learning objectives. Educational content included a general review of the topic as background and then relevant evidence-based medicine with recent or landmark publications highlighted. Controversial or challenging aspects of each topic were also presented to spur discussion regarding how to communicate effectively with families. Tools to aid in effective communication, such as the use of a shared decision-making technique,14 were also included when applicable. The sessions also incorporated a variety of innovative educational methods, including team-based problem-solving, pop quizzes, Web-based audience polling, and expert panelists/discussants (Table 2).
Survey Design and Analysis
A paired pre–post survey study design was used to assess improvements in knowledge and perceptions of the topic of each conference by the resident learners. The anonymous surveys were short in length to incentivize completion (Fig 1). They included 3 main areas of study: (1) a write-in medical knowledge question (eg, “for an infant with fever of unknown source aged 29 to 60 days, please name 2 of the criteria by history for the patient to be considered low risk”); (2) a 5-point Likert-scale question (scale of 1–5, with 1 being “not at all confident” and 5 being “very confident”) regarding perceived confidence of the learners in communicating about a specific topic with patients and families; and (3) a 5-point Likert scale regarding learner perception on the level of innovation of the conference compared with other regularly attended didactic sessions (postsession survey only, scale of 1–5, with 1 being “not at all innovative” and 5 being “very innovative”). The respondents were also asked to specify their level of training. The surveys were completed upon entering each of the 6 conference sessions and then again at the end of the presentation. Surveys were paired and compared presession versus postsession for analysis; data that did not include both a presurvey and postsurvey were not included in the analysis. The medical knowledge questions were categorized as correct versus incorrect, as determined by the primary investigator by using objective evidence presented in the corresponding learning session; any unclear answers were reviewed by additional study team members for categorization. For these dichotomous data obtained in the medical knowledge question (correct versus incorrect), McNemar’s test was used to evaluate a shift in the proportion correct from presession to postsession. For the 5-point Likert scale confidence question, the Wilcoxon signed rank test was used to evaluate a change in perceived confidence presession to postsession. A P value <.05 was used to determine significance. Descriptive statistics, median, and interquartile ranges were used to describe the perceived level of innovation for each conference.
Survey data are summarized in Table 3. Total survey responses received in each session ranged from 24 to 43, but only paired surveys, for which both a presession and postsession survey were returned, were analyzed (n = 17 to n = 38). On average across the year-long conference series, the learners present in the sessions comprised 30% medical students, 30% interns, 25% second-year residents, and 15% third- to fifth-year residents. A statistically significant increase in learner medical knowledge was seen between presession and postsession for all 6 individual topics (P < .001). For example, the percentage of learners who correctly answered the medical knowledge question about bronchiolitis increased from 22% presession to 97% postsession (P < .001). Confidence in communicating about the topic with families was also significantly increased for each topic (P < .01). For example, presession learners rated their confidence in communicating about the use of hypertonic saline in bronchiolitis with families as a 2 on a Likert scale of 1 to 5. This finding improved to a median of 4 postsession, representing a statistically significant improvement (P < .001). All sessions were rated as highly innovative, with median scores of 4 or 5 for every session. The number of responses was too low to stratify analysis according to level of training.
This study used a systematic curriculum development process to create and implement an innovative HM pediatric learner conference series. Distinct medical knowledge and perceived confidence in communicating with families increased presession to postsession for each topic, and sessions were rated as favorably innovative compared with other conferences the learners regularly attend.
The use of a systematic approach13 to creating our curriculum allowed us to incorporate the needs of our learners into our study design, strengthening its appeal to our targeted audience. By including overall and individual topic goals and objectives in line with the Accreditation Council for Graduate Medical Education and pediatric HM core competencies,11,12 we guaranteed that our sessions also provided aspects of the fundamental inpatient pediatric knowledge required for proficiency. By focusing on medical content, learners were empowered to consider how to best apply this new medical knowledge acquired from the teaching sessions to bedside discussions with families, and this scenario led to an improvement in learner confidence. In addition, we incorporated tips to effectively discuss the topics with patients and families, which also facilitated discussion regarding communication skills.
Interestingly, presession survey results revealed that learners often had gaps in medical knowledge that may not be anticipated by faculty teachers. For example, when asked to define 2 historical criteria that would deem an infant with fever of uncertain source “low risk,”15 no learners were able to correctly answer the question. Similar low percentages of presession knowledge in other topics further highlight the importance of formal pediatric HM curricula in teaching future practitioners core pediatric areas.
Our learners also requested that sessions be fun and interactive. To make the sessions innovative, we used a variety of strategies congruent with the values of adult, self-directed learners,4,5 who welcome learning experiences that are motivated by their personal interests and can be integrated into their lives. The use of multimodal teaching techniques allowed for engagement of learners of various levels and with different learning preferences. We frequently incorporated real-life patient experience that involved independent or team approaches at problem-solving. In addition, learners were encouraged to ask questions, often of experts in the field, and to participate in anonymous polls that allowed for low-pressure, independent interaction; polls also engage young learners’ technology-savvy approach to learning. Our curriculum was in line with Kirkpatrick’s model of teaching principles of adult learning.16 Our sessions appeared to incite reaction, the first level of Kirkpatrick’s model, as evidenced by rating them as highly innovative. We also believe we reached the second level of learning during the sessions, as evidenced by our presession to postsession survey improvement, although the number of survey questions was small. Although we hope that we contributed to our learners reaching the top levels of the model, behavior change on the job, and later additional results, we were unable to assess our contribution to any sustained knowledge because these learners are exposed to the topics in a variety of modes during training (eg, clinical rotations with direct patient care, reading text, other didactic sessions).
These study results add to the evidence that supports the value and utility of innovative educational techniques in facilitating active learning and affecting the clinical practices of physician trainees.17–19 One previous study compared pediatric resident perceptions of the effectiveness of a computer-based tutorial versus facilitated case-based discussions about learning disorders. The study found that facilitated case discussions provided more opportunities to interact with expert faculty, discussions made the topic more relevant to clinical practice, and, most importantly, the learning experience would change their future patient management.17 Another study evaluated the impact of a series of interactive educational interventions focused on teaching pediatric residents about breastfeeding. 18 The intervention consisted of 4 sessions that incorporated a number of innovative techniques, including discussion groups, role play, and panel discussions with breastfeeding mothers. Similar to our research, this study reported increases in resident knowledge and confidence, which suggests the clinical behaviors of pediatric residents can be enhanced through innovative educational opportunities.
Within the field of pediatric HM, other curricula have demonstrated the effectiveness of innovation to teach topics relevant to inpatient general pediatrics. One such widespread initiative is the national dissemination of the I-PASS (illness severity, patient summary, action items, situation awareness and contingency plans, and synthesis by receiver) handoff curriculum to improve patient handoffs among resident providers.20,21 Survey results indicate that the majority of resident and faculty providers using the novel mnemonic tool believed it facilitated the acquisition of skills pertinent to patient care activities.20 A different group of hospitalists used the pediatric HM competencies11,12 to develop a pediatric hospitalist faculty development curriculum.22 The curriculum included innovative strategies in both live and online topic presentations; surveys revealed participants were likely to change practice based on the majority of topics presented. Our curriculum adds to these studies as examples of educational initiatives within pediatric HM that effectively teach important aspects of the field to providers.
Our study had several limitations. First, our needs assessment was limited to only 3 residents, which may not have been representative of interests of the larger group as we prepared for curriculum design; however, sessions were rated as highly innovative, suggesting they met learners’ needs. Second, not all session attendees completed both the before and after-session surveys, as survey completion was voluntary. As a result, our findings may suffer from nonresponse or participation bias. In addition, our study sample size prohibited potentially important subgroup analyses of medical knowledge and perceived communication skills (eg, according to level of training). Third, our results show an improvement in correct topic specific questions shortly after the educational session. By including only 2 comparative questions, the assessment may not reflect true gain/retention in knowledge or communication skill. Furthermore, data presession to postsession only apply to a finite amount of time. Due to the difficulty of ensuring that learners are present at every session within the rotating pediatric resident schedule, assessment of a longer time period for knowledge retention analysis was not possible. Fourth, the findings in this study cannot be correlated to a measurable patient outcome improvement. Finally, this curriculum was created and studied at a single institution and thus may require further testing before implementation at other institutions; however, because it was based on the HM core competencies list11,12 and uses innovative educational strategies that are appealing to learners, it could likely be easily incorporated into the formal teaching conference framework used by many residency programs.
In our own center, we have continued 6 unique sessions per year for an additional 2 years. The sessions continue to be highly regarded and span a variety of HM competency topics.
A systematic approach to curriculum design was used to develop a pediatric HM conference series that led to increased knowledge and confidence in communicating with patients and families. Innovative teaching methods are valuable in engaging pediatric learners.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- ↵Duty Hours. ACGME standards. Available at: www.acgme.org/acgmeweb. Accessed January 28, 2016
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