Residents as teachers in Canadian paediatric training programs: A survey of program director and resident perspectives

BACKGROUND:

The importance of the teaching role of residents in medical education is increasingly being recognized. There are little data about how this role is perceived within training programs or how residents develop their teaching skills. The aims of the present study were to explore the perspectives of Canadian paediatric program directors and residents on the teaching role of residents, to determine how teaching skills are developed within these programs, and to identify specific areas that could be targeted to improve resident teaching skills and satisfaction.

METHODS:

Program directors and residents in Canadian paediatric residency programs were surveyed about the scope of teaching performed by residents, resident teaching ability and resources available for skill development.

RESULTS:

Responses were received from 11 of 13 program directors contacted. Nine programs agreed to have their residents surveyed, and 41% of residents in these programs responded. Directors and residents agreed that residents taught the most on general paediatric wards, and that medical students and residents were the most frequent recipients of resident teaching. While 72% of directors reported that instruction in teaching was provided, only 35% of residents indicated that they had received such training. Directors believed that residents needed improvement in providing feedback, while residents wanted help with teaching at the bedside, during rounds and in small groups. Teaching performance was included in rotational evaluations in most programs, but residents were often uncertain of expectations and assessment methods.

CONCLUSION:

There is a general consensus that residents play an important teaching role, especially on the inpatient wards. Residents’ ability to fill this role could be enhanced by clearer communication of expectations, timely and constructive feedback, and targeted training activities with the opportunity to practice learned skills.     

Implementation and evaluation of a simulation curriculum for paediatric residency programs including just-in-time in situ mock codes

OBJECTIVE:

To develop, implement and evaluate a simulation-based acute care curriculum in a paediatric residency program using an integrated and longitudinal approach.

DESIGN:

Curriculum framework consisting of three modular, year-specific courses and longitudinal just-in-time, in situ mock codes.

SETTING:

Paediatric residency program at BC Children’s Hospital, Vancouver, British Columbia.

INTERVENTIONS:

The three year-specific courses focused on the critical first 5 min, complex medical management and crisis resource management, respectively. The just-in-time in situ mock codes simulated the acute deterioration of an existing ward patient, prepared the actual multidisciplinary code team, and primed the surrounding crisis support systems. Each curriculum component was evaluated with surveys using a five-point Likert scale.

RESULTS:

A total of 40 resident surveys were completed after each of the modular courses, and an additional 28 surveys were completed for the overall simulation curriculum. The highest Likert scores were for hands-on skill stations, immersive simulation environment and crisis resource management teaching. Survey results also suggested that just-in-time mock codes were realistic, reinforced learning, and prepared ward teams for patient deterioration.

CONCLUSIONS:

A simulation-based acute care curriculum was successfully integrated into a paediatric residency program. It provides a model for integrating simulation-based learning into other training programs, as well as a model for any hospital that wishes to improve paediatric resuscitation outcomes using just-in-time in situ mock codes.     

Residents as health advocates: The development, implementation and evaluation of a child advocacy initiative at the University of Toronto (Toronto, Ontario)

BACKGROUND AND OBJECTIVE:

Advocacy is an integral part of a paediatrician’s role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario).

METHODOLOGY:

Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents.

RESULTS:

Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback.

CONCLUSIONS:

Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.     

An innovative on-call system for paediatric residency programs: The alternate night float

BACKGROUND:

Night-float systems, in which residents work consecutive nights, have been increasingly adopted in paediatric programs, but may be detrimental to residents’ sleep and mood.

OBJECTIVE:

To describe the self-reported impact of a novel system consisting of two consecutive weeks of 16 h overnight shifts every second day that was piloted at the Children’s Hospital of Eastern Ontario (Ottawa, Ontario).

METHODS:

A survey of 28 senior paediatric residents examined their experience with the alternate night-float system in three domains (patient care, resident professional development and well-being) and their comparison of the system with the traditional overnight on-call system.

RESULTS:

Twenty-six of 28 residents responded. Nearly all (96%) felt familiar with important details of inpatients and that handover was effective (92%). Results were mixed for professional development, with concerns about the quality of supervisors’ feedback and perceived difficulty in attending daytime teaching. All residents believed that the night-float system provided a better learning experience compared with the traditional system. Less than 35% considered fatigue to be a notable problem, although 20% increased use of sleep aids or stimulants beyond their typical use. Ninety-six percent believed their workload was appropriate. All residents felt equally or less fatigued under the night-float system compared with the traditional system. Ninety-six percent recommended that the night-float model continue as the on-call system.

CONCLUSIONS:

This novel night-float system is an alternative method of providing paediatric inpatient night coverage because it meets duty hour regulations and has strong resident approval. Studies to examine its impact on residents and patient care in comparison with other systems are warranted.     

Prevalence and indications for video recording in the health care setting in North American and British paediatric hospitals

BACKGROUND:

Health care video recording has demonstrated value in education, performance assessment, quality improvement and clinical care.

METHODS:

A survey was administered to paediatric hospitals in Great Britain, Canada and the United States. Heads of departments or delegates from six areas (emergency departments [EDs], operating rooms, paediatric intensive care units [PICUs], neonatal intensive care units [NICUs], simulation centres and neuroepilepsy units) were asked 10 questions about the prevalence, indications and process issues of video recording.

RESULTS:

Seventy hospitals were surveyed, totalling 307 clinical areas. The hospital response rate was 100%; the rate for clinical departments was 65%. Sixty-six hospitals (94%) currently use video recording. Video recording was used in 62 of 68 (91%) operating rooms; 36 of 69 (52%) PICUs; 35 of 67 (52%) NICUs; 12 of 65 (19%) EDs; seven of eight (88%) neuroepilepsy units and 13 of 14 (93%) simulation centres. Education was the most common indication (112 of 204 [55%]). Most sites obtained written consent. Since the introduction of more strict privacy legislation, 11 of 65 (17%) EDs have discontinued video recording.

CONCLUSION:

The present study describes video recording practices in paediatric hospitals in North America and Great Britain. Video recording is primarily used for education and most areas have a consent process.     

Data monitoring committees, interim analysis and early termination in paediatric trials

Aim: To evaluate whether paediatric randomized clinical trials (RCTs) adopt recent guidance on Data Monitoring Committees (DMCs), interim analysis and early termination. Methods: We reviewed paediatric RCTs that reported on DMCs, interim analysis or early termination, published in eight general medical and paediatric journals (2005–2007). We searched full‐text databases for eligible trials and recorded predefined parameters on each item. Reported activities were compared with current scientific guidance. Results: A total of 110 of 648 paediatric trials (17%) reported on DMC, interim analysis or early stopping. Various approaches for convening a DMC were identified; information on DMC composition and independence was limited. Strict predefined statistical stopping ‘rules’ were reported in 10 of 23 trials, and interim analyses were more frequently performed on efficacy than on safety outcomes (39/45 vs 27/45). No adjustment for repeated testing was reported in 11 of 33 trials reporting monitoring methods and in 7 of 17 early terminated trials. Validity of results from early stopped trials was threatened by small sample sizes. Incomplete reporting hampered a full analysis. Conclusion: Few paediatric trials report on DMCs’ roles, interim analysis or early stopping. Heterogeneous practices and apparent shortcomings jeopardize the validity of trial results. Easily accessible guidelines for the design, conduct and reporting of paediatric DMCs are needed.     

Pitfalls in the design and analysis of paediatric clinical trials: a case of a 'failed' multi-centre study, and potential solutions

Aim: To increase awareness of possible pitfalls in the design and analysis of a multi-centre randomized clinical trial and to give an overview of alternative study designs and their consequences for power analyses in case of limited availability of trial participants.
Methods: Investigation of the assumptions in the power calculation and re-analysis of the original data of a 'failed' trial on the effect of dexamethasone on the duration of mechanical ventilation in young children with respiratory syncytial virus infection. Use of 'boundaries approach' is explored using the data from this trial. A comprehensive overview of the various modern solutions for the design of a subsequent trial in this field is given.
Results: Two frequent major deficiencies of trial design and data analysis are reviewed in depth, i.e. too optimistic assumptions for the sample size calculation and failure to adjust for centre effects.
Conclusion: Critical review of trial assumptions and if necessary sample size recalculation based on an internal pilot by a data monitoring committee is recommended to maximize the probability of obtaining conclusive results.     

Simulated parents: Developing paediatric trainees' skills in giving bad news

Aim:   In curriculum documents for medicine in undergraduate, post-graduate and continuing professional development, there is now a focus on communication skills. The challenges are to place communication skills in the crowded curriculum and then to construct and sustain a programme that uses an evidence-based approach to the teaching and learning of communication skills. For 6 years, we have conducted a programme that involves simulated parents supporting junior medical staff to refine their skills in communication, particularly in giving parents bad news. The aim of our study was to obtain a better understanding of the trainees' experiences of the programme.
Methods:   Nine junior residents individually worked through two scenarios and received feedback from the simulated parent. They gave bad news to a simulated parent/actor who then gave feedback. A recording of the simulation was provided for discussion with a designated colleague at an arranged time. The tapes were then separately appraised by two independent raters – another actor and a paediatrician. Brief written reports and conducted semi-structured interviews provided more insights into the trainees' experience of the simulation. Other participating medical/medical education staff were interviewed about the simulation programme.
Results:   Five themes emerged from the qualitative data: timeliness, emotional safety, the complexity of communication, practical usefulness and the challenge of effecting change. In addition, the ratings of the videos helped to clarify those 'parent-centred' communication skills that trainees may neglect in difficult conversations: 'ask about support', 'encourage the parent to ask questions' and 'repeat key messages'.
Conclusion:   The evaluation highlighted the value of an early-career experiential programme to highlight the importance of communication skills in post-graduate paediatrics practice.     

Methods for evaluating the taste of paediatric formulations in children: A comparison between the facial hedonic method and the patients' own spontaneous verbal judgement

The aim of the study was to evaluate two essentially different methods of assessing differences in children's taste preferences with regard to five different paediatric penicillin formulations. The study was performed with a parallel group design comparing five groups. A taste evaluation was recorded in 103 children with upper respiratory tract infections after a single therapeutic test dose. First the patient's own spontaneous verbal judgement was recorded then a judgement was arrived at using a hedonic scale of facial expressions. Both judgements were passed immediately and also 3–4 minutes after the test dose. In the children who were 6 years of age or younger, a better discrimination of taste differences between formulations was achieved by using the patients' own spontaneous verbal judgements instead of the facial hedonic method. Both methods seem appropriate in older children, but the hedonic scale is preferable since its use implies a more standardised procedure.     

RADPED: an approach to teaching communication skills to radiology residents

Background: The Accreditation Council for Graduate Medical Education mandates that radiology residency programs teach communication skills to residents. Objective: The purpose of this paper is to present a mnemonic, RADPED, that can be used to enhance communication in the radiology setting. It reminds the resident of the salient points to address during an imaging encounter with pediatric patients and their families for the purpose of enhancing communication. Materials and methods: Recent history and research in medical communication are reviewed. Various communication guides used by primary care physicians, such as SEGUE, and the Kalamazoo consensus statement are discussed. This methodology was adapted into a format that could be used to teach communication skills to radiology residents in the context of an imaging encounter. Results: RADPED reminds the resident to establish rapport with the patient, ask questions as to why the patient and family are presenting for the study, discuss the exam, perform the procedure, use exam distractions, and discuss the results with the referring physician and family when appropriate. This guide is available with movie clips as part of an on-line pediatric radiology curriculum, . Summary: This simple memory aid promotes the key points necessary to optimize the radiology residents encounter with pediatric patients and their families.This paper was presented at the Society for Pediatric Radiology 46th annual meeting in San Francisco, California, 7–10 May 2003.     

European paediatric research and children's therapeutic needs. A trial review

AIM: To evaluate the current paediatric therapeutic research situation in Europe with respect to paediatric needs and drug therapies. METHODS: Data from ongoing and published paediatric drug therapy trials from 2004 to 2007 were evaluated and compared to the European Medicines Agency (EMEA) priority list for studies on paediatric medicinal products. Ongoing trial data from the DEC-net paediatric trial register and published trials from two biomedical databases were used. RESULTS: In all, 379 trials from the 27 European Union (EU) countries were found (most common country: Italy, 18.2%). The major disease area covered was 'infectious and parasitic diseases' (21.4%). Only four of 25 EMEA priority conditions were addressed, the most common were 'malignant diseases' (18.2% of trials) and 'asthma' (3.2%). A subset of 190 published trials, representing the same four countries that participated in DEC-net (France, Italy, Spain and United Kingdom), was compared to the register's 257 ongoing trials. Some significant differences in disease areas covered were found. Concerning the EMEA priority conditions, the ongoing research addressed more of them. CONCLUSION: Paediatric research is being carried out in Europe, but this study found a general lack of overlap between therapeutic needs and research. The Paediatric Regulation will hopefully lead to research that is more focused on children's needs.     

Massage therapy for paediatric procedural pain: A rapid review

BackgroundPain is a common paediatric problem, and procedural pain, in particular, can be difficult to manage. Complementary therapies are often sought for pain management, including massage therapy (MT). We assessed the evidence for use of MT for acute procedural pain management in children.MethodsWe searched five main databases for (i) primary studies in English, (ii) included children 0 to 18 years of age, (iii) compared MT for procedural pain management to standard care alone or placebo, and (iv) measured pain as the primary or secondary outcome. The data were extracted by one author and verified by a second author. Randomized controlled trials were evaluated using the Cochrane Risk of Bias tool.ResultsEleven paediatric trials of procedural pain in neonatal, burn, and oncology populations, a total of 771 participants, were identified. Eight reported statistically significant reductions in pain after MT compared to standard care. Pain was measured using validated pain scales, or physiologic indicators. The studies were heterogeneous in population, techniques, and outcome measures used. No adverse events associated with MT were identified.ConclusionMT may be an effective nonpharmacologic adjunct for management of procedural pain in children.     

Computer based evaluation of clinical skills

Computers have the potential to evaluate clinical skills in innovative and economical ways. Since no single program can accomplish the complete evaluation, faculty members need to develop strategies to match the desired skill which is to be evaluated with available computer programs. Additionally, the systems should produce information that is not available in equal quality from other sources, should be cost effective, and be relatively easy to create and maintain. This paper describes a medical simulation CAMPS, a multiple choice question generator, PILOT language based interactions and imaging systems as potential evaluation programs. Experience with CAMPS is described in detail indicating its usefulness and limitations.     

Urban paediatric trauma due to stab wounds: an Israeli hospital experience

Objective:  To assess the incidence and types of stab wounds to hospitalized children and adolescents.
Subjects:  The sample consisted of patients, age 6–18 years, who were admitted to our hospital with sustained injury between 1991 and 2007.
Results:  In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991–2000 period, and 71 during the 2001–2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0).
Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min).
Conclusion:  This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.     

Ethics application protocols for multicentre clinical studies in Canada: A paediatric rheumatology experience

INTRODUCTION:

Individual institutions govern research ethics applications and each must administer and regulate their own protocols. Variations in ethics review procedures and expectations among centres impose impediments to efficiently conducting multicentre studies.

METHODS:

Observations relating to preparing multisite ethics documents for a study conducted by Canadian paediatric rheumatology investigators are described. Research ethics applications from the 12 participating centres were compared.

RESULTS:

Although the applications were similar in their content, they differed in their formatting. All applications shared a commitment to ensuring that the study conformed to exemplary ethical standards.

CONCLUSIONS:

There is wide variation in the multicentre clinical study ethics application process at the institutional level. Considering the common fundamental elements required by all ethics review boards, the present study conceptualized introducing a discipline-specific uniform ethics application process acceptable to all Canadian research ethics boards. This may be a more efficient strategy that could help lessen the burden of collaborative research.     

Surgical skills training in the laparoscopic era: the use of a helping hand

The aim of this study was to evaluate whether a training programme involving an assessment exercise performed on a laparoscopic trainer model leads to an improvement in the acquisition of laparoscopic skills in surgical trainees. Subjects were recruited from a cross-section of surgical trainees at the Great Ormond Street Hospital, Department of Surgery and the Institute of Child Health. All subjects completed both a baseline laparoscopic surgical skills questionnaire and three exercises on a new laparoscopic trainer model. Thirteen subjects completed both the baseline questionnaire and all three assessment exercises. These subjects exhibited a wide range of previous experience in laparoscopic surgery. Sixty-nine percent of subjects showed a significant improvement in the assessment exercise score with training (ANOVA; P = 0.01). Sixty-two percent of subjects showed a greater improvement between exercises 2 and 3 than between exercises 1 and 2. The difference in score between exercises 1 and 2 was not statistically significant (P = 0.597), whereas the difference in score between both exercises 2 and 3 and exercises 1 and 3 was statistically significant (P = 0.018 and P = 0.005, respectively). The double glove training model is thus a simple, inexpensive, and easily reproducible tool that elicits a significant improvement in laparoscopic surgical skills in surgical trainees with a broad range of previous laparoscopic experience. It can therefore be used as part of a training programme to facilitate the acquisition of laparoscopic skills in a paediatric surgery setting.     

The stethoscope as a vector of infectious diseases in the paediatric division

AIM: Nosocomial infections are of great concern in hospital settings, and even more so in the paediatric ward. Health professionals and their medical equipment have long been known to act as vectors of infectious diseases. This study aimed at evaluating the presence of bacterial pathogens on the stethoscopes of medical personnel in the paediatric division. METHODS: Forty-three stethoscopes belonging to senior physicians, residents, interns and medical students at the paediatric ward were sampled. Bacterial cultures and antibiotic sensitivity testing were carried out. RESULTS: All but six bacterial cultures were positive (85.7%). Staphylococcal species were the most common contaminants (47.5%). One case of methicillin-resistant Staphylococcus aureus was encountered. Gram-negative organisms were isolated in nine different samples (21%) including one case of Acinetobacter baumannii in the neonatal intensive care unit. CONCLUSION: Most stethoscopes harbour potential pathogens. The isolation of Gram-negative organisms pose a real risk of spreading potentially serious infections, especially in the setting of intensive care departments. Apparently, the current recommendations of regular disinfection of stethoscopes are not carried out by health personnel that participated in the study.     

Transfusion-related acute lung injury in the Canadian paediatric population

BACKGROUND:

The incidence of transfusion-related acute lung injury (TRALI) in adults is approximately one per 5000 transfusions. The Canadian Paediatric Surveillance Program undertook the present study to determine the incidence of TRALI in the paediatric population and to describe the characteristics and outcomes of children with TRALI.

METHODS:

The present surveillance study was conducted over a three-year period.

RESULTS:

Four TRALI cases were reported, yielding an incidence rate of 1.8 per 100,000 transfusions. The degree of severity varied: in two patients, only supplemental oxygen was necessary, while the other two required mechanical ventilation.

CONCLUSION:

TRALI was reported much less often in the present study compared with adult studies; therefore, it needs to be determined whether TRALI occurs less frequently in children, or alternatively, whether TRALI is recognized less often in children. The possibility that neonates who undergo cardiac surgery are at greater risk of TRALI than other patients should be addressed in future studies.