A Qualitative Analysis of Assessment and Evaluation Practices Within the Individualized Curriculum.

OBJECTIVE: The Accreditation Council of Graduate Medical Education requires an "individualized curriculum" (IC) in pediatric residency. A shared understanding across programs of methods to evaluate the IC is lacking. We explored pediatric program leaders' perceptions of assessment and evaluation within the IC to further understand and inform most useful practices. METHODS: We conducted a phenomenology study using semi-structured interviews to 1) determine what IC assessment and evaluation strategies are utilized in pediatric residency programs, and 2) explore program leaders' perceptions of the feasibility and value of assessment and evaluation in the IC. We recruited a purposive sample of leaders from 15 pediatric residency programs of various sizes and regions. Interviews were recorded and transcribed. Data were analyzed to produce themes. RESULTS: Three themes arose from our analysis: 1) Systematic assessment of the IC, though desired, is not robust in pediatric residency training; 2) Program differences present unique barriers and facilitators that impact the feasibility of assessment within the IC; and 3) Meaningfulness of assessment in the IC varies by stakeholder. Themes reflected perspectives on individual learner assessment and program evaluation. CONCLUSIONS: While systematic assessment and evaluation of the IC in pediatric residency training is lacking, program leaders desire feasible strategies that are meaningful to the resident, the program, and its leadership team. Leveraging current assessment and evaluation tools and aligning new assessment strategies could promote the integration of IC assessment with other assessments, minimizing burden. More structured IC assessment and evaluation could inform how to best achieve curricular goals of the IC.

Three Years of X + Y Scheduling: Longitudinal Assessment of Resident and Faculty Perceptions.

OBJECTIVE: Five pediatric residency programs implemented true X + Y scheduling in 2018 where residents have continuity clinic in "blocks" rather than half-day per week experiences. We report the impact X + Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences over a 3-year timeframe. METHODS: Electronic surveys were sent to residents and faculty of the participating programs prior to implementing X + Y scheduling and annually thereafter (2018-2021). Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotations. Data were analyzed using z-tests for proportion differences. RESULTS: One hundred and eight six residents were sent the survey preimplementation and 254 to 289 postimplementation with response rates ranging from 47% to 69%. Three hundred and seventy-eight to 395 faculty members were sent the survey with response rates ranging from 26% to 51%. Statistically significant (P < .05) sustained perceived improvements over 3 years with X+Y were seen in outpatient continuity, inpatient workflow, and time for teaching both inpatient and in continuity clinic. CONCLUSIONS: X + Y scheduling can lead to perceived improvements in various aspects of pediatric residency programs. Our study demonstrates these improvements have been sustained over 3 years in the participating programs.

Impact of X+Y Scheduling on Pediatric Resident and Faculty Perceptions of Education and Patient Care.

PURPOSE: Traditional half-day per week continuity clinic experiences can lead to fragmented education in both the inpatient and outpatient arenas. Five pediatric residency programs were granted the ability from the ACGME to create X+Y scheduling where residents have continuity clinic in "blocks" rather than half-day per week experiences. The aim of this study is to assess the impact X+Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences. METHODS: Electronic surveys were sent to residents and faculty of the participating programs both prior to and 12 months after implementing X+Y scheduling. Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotation experiences using a 5-point Likert Scale. Data were analyzed using z-tests for proportion differences for those answering Agree or Strongly Agree between baseline and post-implementation respondents. RESULTS: Hundred and twenty-six out of 186 residents (68%) responded preimplementation and 120 out of 259 residents (47%) responded post-implementation. 384 faculty members were sent the survey with 51% response pre-implementation and 26% response at 12 months. Statistically significant (P < .05) improvements were noted in resident and faculty perceptions of ability to have continuity with patients and inpatient workflow affected by clinic scheduling. CONCLUSIONS: From both resident and faculty perspectives, X+Y scheduling may improve several aspects of patient care and education. X+Y scheduling could be considered as a potential option by pediatric residency programs, especially if validated with more objective data.

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.

Justifications for Discrepancies Between Competency Committee and Program Director Recommended Resident Supervisory Roles.

OBJECTIVE: To explore justifications for differences between summative entrustment decisions made about pediatric residents by individuals who are charged with the review of residents (clinical competency committee, or CCC, members) and those who ultimately make final summative decisions about resident performance (program directors, or PDs). METHODS: Individual CCC member and PD supervisory role categorizations were made in the 2015 to 2016 academic year at 14 pediatric residency programs, placing residents into 1 of 5 progressive supervisory roles. When PD recommendations differed from CCC members, a free-text justification was requested. Free-text responses were analyzed using manifest content analysis. RESULTS: In total, 801 supervisory role categorizations were made by both CCC members and PDs, with the same recommendations made in 685 cases. In the 116 instances of discrepancy, PDs assigned a lower level of supervisory responsibility (n = 73) more often than a greater one (n = 43). When moving residents to a greater supervisory role category, PDs had more justifications anchored in resident performance than experience. When moving residents to a lower supervisory role categorization, PDs conversely noted experience more than performance. CONCLUSIONS: PDs provide more justifications anchored in resident performance when moving residents to a greater supervisory role category compared with CCC members. However, when moving residents to a lower supervisory role categorization, they note experience more than performance. These patterns may or may not be entirely consistent with a competency-based approach and should be explored further.

Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline.

BACKGROUND: Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. METHODS: This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. RESULTS: Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. CONCLUSION: Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. LEVEL OF EVIDENCE: Level III- retrospective comparative study.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns.

BACKGROUND: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. METHODS: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. RESULTS: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. CONCLUSIONS: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Decreasing Exposure to Radiation, Surgical Risk, and Costs for Pediatric Complicated Pneumonia: A Guideline Evaluation.

OBJECTIVES: This report describes the creation and successful implementation of a complicated pneumonia care algorithm at our institution. Outcomes are measured for specific goals of the algorithm: to decrease radiation exposure, surgical risk, and patient charges without adversely affecting clinical outcomes. METHODS: We describe steps involved in algorithm creation and implementation at our institution. To depict outcomes of the algorithm, we completed a retrospective cohort study of hospitalized pediatric patients with a diagnosis of complicated pneumonia at a single institution between January 2010 and April 2016 who met criteria for the algorithm. Charts were manually reviewed and data were analyzed via Wilcoxon rank sum, χ2, and Fisher's exact tests. RESULTS: Throughout the algorithm creation process, our institution began to see a change in practice. We saw a statistically significant decrease in the number of patients who underwent a chest computed tomography scan and an increase in patients who underwent a chest ultrasound (P < .001). We also saw an increase in the use of chest tube placement with fibrinolytics and a decrease in the use of video-assisted thoracoscopic surgery as the initial chest procedure (P ≤ .001) after algorithm implementation. These interventions reduced related charges without significantly affecting length of stay, readmission rate, or other variables studied. CONCLUSIONS: The collaborative creation and introduction of an algorithm for the management of complicated pneumonia at our institution, combined with an effort among physicians to incorporate evidence-based clinical care into practice, led to reduced radiation exposure, surgical risk, and cost to patient.

Renal Calculi: An Unusual Presentation of T-Cell Acute Lymphoblastic Leukemia.

Spontaneous tumor lysis syndrome is a rare initial presentation of hematologic malignancy in children that typically presents with complications of electrolyte derangement, specifically hyperkalemia, hyperphosphatemia, and hyperuricemia. We report a case of a 5-year-old boy who presented to the emergency department with gross hematuria, abdominal pain, and vomiting and was ultimately diagnosed with uric acid nephrolithiasis and acute renal failure secondary to spontaneous tumor lysis syndrome in the setting of T-cell acute lymphoblastic leukemia. Tumor lysis syndrome is considered an oncologic emergency, and in this case, the child required urgent treatment with potassium-binding agents, rasburicase, and hemodialysis. This case demonstrates that occult hematologic malignancy should be suspected in cases of nephrolithiasis and acute renal failure when found in conjunction with hyperuricemia despite a normal complete blood count at the time of presentation.