structured career-centered block time in a pediatric residency program

Development and evaluation of practice using Entrustable Professional Activities (EPAs; Ten Cate and Scheele, Acad Med 2007;82:542-547)

Characteristics of an EPA (e.g., serve as primary pediatrician for children with complex acute problems needing subspecialty care; screen for normal/abnormal behavior and development and manage or provide subspecialty referral; diagnose and manage common childhood injuries and refer those needing advanced treatment)

• Part of essential professional work in a given context

• Requires adequate knowledge, skill, attitude

• Leads to recognized output of professional labor

• Confined to qualified personnel

• Independently executable in a defined time frame

• Observable and measurable in its process and outcome (well done or not well done)

• Reflects one or more competencies

Evaluation of an EPA

• Based on supervisors’ evaluations of resident’s knowledge and skills, awareness of limits, conscientiousness and truthfulness (Kennedy et al., Acad Med. 2008;83(10 Suppl):S89–S92) and on resident patient logs and written self-evaluations

• Summary: Does the mentor trust resident to perform the EPA without direct supervision?

OSCE results

Structured Clinical Observations

Activity log with written self- evaluations and program evaluations

Satisfaction surveys: residents and faculty

Focus groups: residents and faculty

ABP written examination scores

Structured Career-Centered Block Time in a Pediatric Residency Program

ABSTRACT

TITLE:

Structured Career-Centered Block Time in a Pediatric Residency Program

BACKGROUND:

The structure of pediatric residency education traditionally rests on the unstated assumption that residents (and their future patients) are best served by 33 months of the broadest possible exposure to pediatrics. Yet most pediatric residents have chosen an ambulatory primary care or hospitalist/subspecialist career during or before PGY1. Residency programs need to explore ways of incorporating more deliberate practice (Ericsson KA., Acad Med 2004;79(supp)S70-S81) to prepare for post-residency careers.

OBJECTIVE:

To improve resident preparation for 4 careers within pediatrics: 1. Primary care with ready access to hospitalists and subspecialists; 2. Primary care without ready access to hospitalists and subspecialists; 3. Hospitalist; 4. Subspecialist.

METHODS:

Individually designed, monitored, mentored and evaluated 4-month blocks during PGY3 .

RESULTS:

Preliminary.

CONCLUSI ONS:

To be determined.

In kind support provided by the Initiative for Innovation in Pediatric Education (IIPE)

BACKGROUND

Month 1 Month 2 Month 3 Month 4

Inpatient: teaching and non-teaching services. Begin work on QI project.

Anesthesia/sedation, procedures, consults on non-medical pts.

Longitudinal experience

Adam A. Rosenberg, MD, M. Douglas Jones, Jr., MD, University of Colorado School of Medicine, The Children’s Hospital, Aurora, CO

METHODS

Residents may choose to spend 4 consecutive months during PGY3 in concentrated preparation for a specific career within pediatrics.

Early in PGY2 the Program Director, block or fellowship director, and primary mentor meet with residents to develop components of their programs.

Components:– Relevant outpatient experiences – (e.g., for primary care: mental and

behavioral health, sports medicine, allergy, dermatology)– QI project– Principles and practice of medical education for hospitalist and subspecialty

blocks– Procedural component if relevant – (e.g., for hospitalist and primary care

without access to hospitalists/subspecialists: cardiopulmonary resuscitation, procedural sedation, vascular access, circumcision)

Residents are individually monitored and mentored during the 4 months.

CONCLUSIONS

Conclusions remain to be determined. Initial interest among residents and faculty has been high. Will it be sustained? Pressing needs are better preparation for careers in primary care and hospitalist medicine. Subspecialty preparation program is less developed at this point.

At the least, career preparation should improve. Will that make a difference to practitioners and patients? If results are promising, our intent is to expand the program to six months.

In kind support provided by the Initiative for Innovation in Pediatric Education (IIPE)

PRELIMINARY RESULTS

• Random rotation structure of residency education fragments learning, evaluation and mentoring, and unintentionally models superficial physician-patient relationships.

• Almost 80% of pediatric residents have chosen between ambulatory primary care and hospitalist/subspecialty pediatrics early in PGY1 (Freed et al., Arch Ped Adol Med, in press.)

o 79% of PGY1s who stated that they would do ambulatory primary care (with or without substantial inpatient care) confirmed that choice as PGY3s.

o 77% of PGY1s who stated that they would do hospitalist or subspecialty pediatrics confirmed those choices as PGY3s.

o 31% of PGY1s were undecided; as PGY3s 47% stated that they would do ambulatory primary care and 38% hospitalist or subspecialty pediatrics; 15% remained undecided.

For additional information please contact:

Adam A. Rosenberg, MDDepartment of PediatricsUniversity of Colorado School of Medicine/The Children’s [email protected]

EPAs developed for primary care and hospitalist

PGY3 baseline OSCE data collected in 2009

Faculty mentors identified

12 PGY3 residents have signed on

Primary care and hospitalist curriculum to begin July 2010

• Recent surveys of primary care, hospitalist and subspecialty pediatricians show different lists of residency education shortcomings. (Pediatrics 2009;123:1suppl; Rosenberg et al., unpublished)

PGY1 (2007)n=2300

PGY3 (2009) n=2300

Primary Care/little or no inpt n=639

Primary Care/substantial inpt n=280

Hospitalistn=115

Fellowshipn=1062

Not suren=204

Primary care/little or no inptn=359

258(72%)

39(11%)

6(2%)

43(12%)

13(3%)

Primary care/substantial inptn=168

56(33%)

65(39%)

9(5%)

35(21%)

3(2%)

Hospitalistn=39

1(2%)

5(13%)

19(49%)

10(26%)

4(10%)

Fellowship n=1026

96(9%)

67(7%)

42(4%)

745(73%)

76(7%)

Not suren=708

228(32%)

104(15%)

39(6%)

229(32%)

108(15%)

OBJECTIVE

To improve resident preparation for 4 careers within pediatrics:

1. Primary care with ready access to hospitalists and

subspecialists; 2. Primary care without ready access to

hospitalists and subspecialists; 3. Hospitalist; 4. Subspecialist.

BLOCKS

Specialty clinic – children with special health care needs

Follow-up of recent hospital discharges

Specialty clinic: e.g., Neurology

Specialty clinic – children with special health care needs

Follow-up of recent hospital discharges

QI projectInpt .psychiatry/ neurology rounds

Continuity clinic

Inpt.psychiatry/ neurology rounds

Teaching

Hospitalist

Primary Care: Access to Hospitalists/Subspecialists



Patients at primary practice site

Specialty clinic: e.g., Psych, Derm, Ortho


Specialty clinicPatients at primary practice site


QI project; practice management


Specialty clinic Specialty clinic

Primary Care: Little Access to Hospitalists/Subspecialists


Block time at a non-metro site

Block time at a non-metro site

Longitudinal experience same for both primary care categories

Subspecialist


Core experience in subspecialty – inpatient and outpatient as appropriate


QI project/ research

Related subspecialty clinic




Procedures or related subspecialty clinic



Education principles and practice


EVALUATION

structured career-centered block time in a pediatric residency program

Documents