Pediatric Residents’ Critical Care Training and the Challenge of the New Accreditation Council for Graduate Medical Education Guidelines

Research Article

Austin J Emergency & Crit Care Med. 2015;2(1): 1009.

Pediatric Residents’ Critical Care Training and the Challenge of the New Accreditation Council for Graduate Medical Education Guidelines

Megan Barry1, Kristin Koehn2, Esma Birisci3, Craig Downs2 and Abdallah Dalabih2*

1Department of Pediatrics, Child Neurology, Vanderbilt University, USA

2Department of Child Health, University of Missouri, USA

3Department of Industrial and Manufacturing System Engineering, University of Missouri, USA

*Corresponding author: Abdallah Dalabih, Department of Child Health, University of Missouri, 400 N Keene Street, Columbia, MO 65201, USA

Received: December 02, 2014; Accepted: January 02, 2015 Published: January 05, 2015

Abstract

Objective: Our objective was to explore the difference in confidence levels reported in pediatric residency program directors’ evaluations compared to pediatric residents’ self-evaluations with regard to performance of eight critical care related skills. Our secondary objective was to determine if spending extra time in a critical care setting had an effect on the residents’ confidence level and perceived competency in those skills.

We elected to perform this survey prior to the adaptation of the new Accreditation Council for Graduate Medical Education (ACGME) recommendations in regard to the number of educational units (four week blocks) spent in a pediatric intensive care unit (PICU) setting.

Methods: We sent an online survey questioning resident exposure to critically ill children and the skills gained during residency to all United States pediatric program directors (PD). The elective anonymous survey targeted program directors and resident physicians in ACGME accredited pediatric training programs. Responses were collected over a two month period. We performed a Chi- Square analysis using IBM SPSS 22.0 and set a significance level of 0.05. The 95% confidence interval was calculated at 95%.

Results: A total of 547 PRs and 124 (49%) PDs responded. Of those, 352 residents had spent at least three months in a critical care setting. Overall, resident confidence in their competency in all categories was lower than the opinion of PDs. Residents required to provide critical care coverage outside of a structured rotation had a significantly higher level of confidence in five of the eight surveyed skills.

Conclusions: Although the PDs had higher confidence in their residents’ competency than the residents’ self evaluations, the survey showed that residents with more exposure to critical care settings had a higher level of confidence in their competency level than those with less exposure. The new ACGME regulations may decrease the critical care training time; we suggest that less time in those settings is unlikely to raise these competencies or the residents’ self-confidence.

Keywords: Pediatric Residency; Critical care; Education; ACGME

Abbreviations

ACGME: American Council of Graduate Medical Education; NICU: Neonatal Intensive Care Unit; PICU: Pediatric Intensive Care Unit; PR: Pediatric Resident; PD: Program Director

Introduction

In the United States, resident physicians are required to complete an Accreditation Council for Graduate Medical Education (ACGME) approved training program before independently practicing medicine. ACGME accredited programs adhere to a set of common training requirements outlining specific numbers of rotations in multiple areas, including medical subspecialties, inpatient medicine, intensive care, emergency medicine, and ambulatory care. The remainder of the required rotations can vary between programs based

on educational exposure and staffing of various services. This model leaves little room for personalized education and creates a “one size fits all” model, rather than focusing on areas of interest to the trainee.

The newly revised ACGME requirements, effective July 1, 2013, were designed to address the need for more individualized training. These new requirements give residents more emphasis on developing tracks of training within each program to better prepare them for the next step after residency. The new requirements decreased the minimum units of education in the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU) to two units each [1]. This is an overall change from the previous requirement of five units total between the different intensive care units.

Pediatricians work hard to establish good rapport with families and to build relationships based upon trust. Due to this relationship, children with urgent medical needs often present to the pediatric office first [2]. Up to 70% of pre-hospital healthcare professionals practice in rural settings [3]. In rural America, pediatricians play an important role in providing care to a large population and may be the only provider with any pediatric experience, including pediatric critical care experience. Rural hospitals often lack support staff that are equipped to manage a critically ill pediatric patient. It is important for a pediatrician to possess the necessary procedural skills and confidence to stabilize an acutely ill patient prior to transfer to a tertiary care center. Many of the skills needed to stabilize an acutely ill child can be learned and practiced in the intensive care setting, which for many pediatricians occurs only during residency.

The goal of our study was to elicit the opinion of current pediatric residents (PR) and pediatric program directors (PD) regarding the level of confidence in procedural competency gained during residency, prior to adapting the new ACGME recommendations. Residents often gain the skills of recognizing critically ill patients and procedural skills during the time spent in the intensive care units. Therefore, our secondary objective was to determine if spending extra time in a critical care setting had an effect on the residents’ confidence level and perceived competency in those skills. We hypothesis that spending less time in a critical care setting will decrease the selfperceived confidence in recognizing and managing critically ill children.

Methods

We designed two online surveys that were approved by our institutional review board (IRB). The surveys consisted of fifteen questions each, including eight questions aimed at identifying the residents’ exposure to critically ill children and their perceived competency level (by the time of graduation) in those skills, from the perspectives of both the PRs and the PDs. The additional questions included the level of training, the number of months of NICU and PICU experience the respondent was to complete by the end of residency, and the number of months of intensive care training the resident had completed prior to answering the survey. We also asked if the residents had any exposure to critically ill children outside of a formal rotation in the critical care setting (e.g. night shift or call coverage). Confidence in competency level in eight skills and procedures was surveyed. To have a better understanding of the responders’ confidence in their ability to perform the skills, we did not give any examples of what determined competency in any skill or procedure. It was up to the respondent to judge his or her own confidence level in performing the surveyed skills.

The email addresses of all United States pediatric and medicinepediatric PDs were obtained from the American Medical Association’s FREIDA online. A link to the survey was included in an email to the PDs along with an explanation of the study. The PDs then made the decision whether or not to forward the survey to their residents. A second reminder email was sent to all program directors two weeks after the initial survey was delivered.

Our primary objective was to explore the difference in the confidence level perceived by pediatric residency program directors and by pediatric residents’ self-evaluation in performing eight critical care related skills. Our secondary objective was to determine if spending extra time in a critical care setting had an effect on the residents’ confidence level and perceived competency in those skills. The data was collected over a period of two months; only residents who spent three or more months in a critical care setting were included in the final analysis, as well as all of the PDs. For the statistical analysis we used a Chi- Square analysis run with IBM SPSS 22.0. A p-value of = 0.05 was considered statistically significant and a 95% confidence interval was also calculated for all of the data points.

Results

Of the 252 residency programs that were contacted a total of 125PDs (49.6%). A total of 547 PRs responded to the survey. It is unknown how many PRs received the survey from their program directors. The responses of residents with three or more months of critical care experience (n=352) at the time of the survey were used for the study. PDs thought residents were more competent than the residents’ self-reported competency in all categories surveyed (Table-1), and this difference was statistically significant.