69CHAPTER 10 Lifelong Learning in Pediatric Critical Care TABLE 10 2 Instructional Techniques According to Potential Costs and Benefits Potential Benefits Potential Costs Didactic learning Traditional[.]
CHAPTER 10 Lifelong Learning in Pediatric Critical Care 69 TABLE Instructional Techniques According to Potential Costs and Benefits 10.2 Potential Benefits Potential Costs Didactic learning Traditional lecture Teacher led Easy to organize Inexpensive (both in teacher time and facility cost) Allows for independent learning Noninteractive Noncollaborative Problem-based learning Small group cases Student led Teacher facilitated Active learning Motivation for learning Allows for complex thought Collaborative and interprofessional Facilitator skill required High faculty, time, and space costs Students may have different styles and learning needs that are incompatible Team-based learning Out-of-class preparation followed by in- class application Student led Teacher facilitated Active learning Motivation for learning Allows for complex thought Collaborative and interprofessional Multiple assessments Facilitator skill required High faculty, time, and space costs Advance student preparation required Students may have different styles and learning needs that are incompatible Simulation Practice of scenarios in simulated environments Teacher led Students active Hands-on skills practiced Literature from other industries (airlines) supports utility Collaborative and interprofessional Resource and time expensive Can seem contrived/unrealistic Social media Online Internet platform Student and teacher Real-time discussion facilitated for knowledge sharing Collaborative and interprofessional and discussion Instant access and knowledge of most up-to-date literature Accreditation Council for Graduate Medical Education Core Competencies, Milestones, and Entrustable Professional Activities The quality of education in training programs is critical to resident and fellow development In 1999, the ACGME initiated an outcome project to design a conceptual framework for education and training according to six general domains of competency.10 The objective of the outcome project was to “ensure and improve the quality of GME.”11 The ACGME recommends that trainees demonstrate (1) patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health; (2) medical knowledge regarding established as well as evolving biomedical, clinical, and cognitive sciences with the ability to apply these concepts to patient care; (3) practice-based learning and improvement involving self-evaluation with regard to patient care, appraisal, and utilization of scientific evidence; (4) interpersonal and communication skills that result in effective information exchange and partnership with patients, their families, and other health professionals; (5) professionalism manifested through a commitment to professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population; and (6) an awareness of and responsiveness to the healthcare system and the ability to use system resources to provide optimal care in a systems-based practice.10 These core domains of competency should be used to guide and coordinate evaluation of all residents or fellows in their development.20 In order to fulfill the promise of the Outcome Project21 to use educational outcome data in accreditation, the Pediatric Milestone Project, a partnership between the ACGME and American Board of Pediatrics (ABP), was designed for the evaluation of resident physicians participating in ACGME-accredited residency Potential distraction Not curated or monitored or fellowship training programs Milestones, which are now routinely used in GME evaluations, describe the performance levels that residents and fellows are expected to demonstrate for skills, knowledge, and behaviors in the six competency domains They are intended to provide a developmental framework of observable behaviors and attributes for learner assessment Although they are not intended to address all competencies, milestones are anchored contextually in the development of the physician in key elements of the competencies The use of milestone assessment has a number of benefits for residents and fellows, including increased transparency of performance requirements by more explicit expectations, better feedback, and enhanced opportunities for early identification of underperformers In addition to the milestones, which have now become standard assessment tools in GME training, most specialties and subspecialties have begun developing entrustable professional activities (EPAs), which can be defined as a representation of the tasks associated with all of the work within a specific field.22,23 Leaders in pediatrics and the pediatric subspecialties, through the work of the ABP, have developed a set of EPAs for both pediatrics and for the pediatric subspecialties PCCM has three subspecialtyspecific EPAs, which supplement several EPAs that cross all specialties, along with those for general pediatrics.24 While EPAs have not yet become a standard method for assessment of learners, data are beginning to emerge on their implementation and use as an assessment tool in this specialty.25,26 Methods of Teaching Given the complexity of the ICU environment and the wide range of learners and educators, leaders of training programs should consider the importance of the quality of teaching 70 S E C T I O N I Pediatirc Critical Care: The Discipline methods The faculty members responsible for supervision in the ICU are the content experts and are often also expected to be the facilitators/educators for learners at a range of levels and from a variety of disciplines To be an effective educator, there must be a clear understanding that a gap often exists between educators and learners regarding perceptions of adequate teaching and optimal teaching techniques.27 One must overcome recognized barriers to education, which include lack of dedicated teaching time, high clinical workload, lack of continuity between faculty and learners, and balancing autonomy and supervision.27–34 These factors are increasingly challenging in the current era.34 Education in the ICU consists of teaching basic principles of pathophysiology and therapeutics but should also include an ongoing, dynamic integration of new medical knowledge and technological advances Table 10.3 demonstrates the broad scope of educational objectives for critical care medicine fellows and TABLE Essential Clinical and Administrative Learning Points 10.3 Clinical Administrative Identify and teach others to identify the need for/provide care for all critically ill patients Evaluate ICU policies and suggest improvements Provide and teach others resuscitation for any patient sustaining a life-threatening event Triage critically ill patients to optimize care delivery within the institution Initiate, manage, and wean patients from mechanical ventilation and teach others new methods and devices for management of respiratory failure Improve resource utilization and maintain patient care quality by facilitating triage of patients to limited institutional critical care beds and caregivers Initiate critical care to stabilize and manage patients who require transport Develop programs and change unit practice to improve care of critically ill patients Instruct other qualified caregivers and the lay public in the theory and techniques of cardiopulmonary resuscitation Develop programs for patient safety monitoring and error reduction Treat cardiogenic, traumatic, hypovolemic, and distributive shock with conventional and state-of-the-art approaches Actively participate in quality assurance processes, including morbidity and mortality conferences, process improvement teams, and the Joint Commission preparation Recognize potential for multiple organ failure and institute measures to avoid or reverse this syndrome Support the process of assessing patient and family satisfaction and participate in tool development and implementation Identify life-threatening electrolyte/acid-base disturbances, provide treatment/monitor outcome Encourage and enhance good relationships with other healthcare providers Identify and initiate discussions involving ethical issues and parents/patients’ wishes in making treatment decisions using advance directives and other methods Understand advanced concepts important for compensation of critical care services and contractual issues related to providing critical care services and performing the business of medicine Diagnose and treat common and uncommon poisonings Develop skills for teaching critical care Teach appropriate use and monitoring of procedural sedation and use advanced pain management strategies Develop and evaluate curriculum changes for ICU caregivers, fellows, and residents Diagnose malnutrition and use/monitor advanced nutrition support methodologies Evaluate, modify, and approve ICU hospital policies Provide invasive and noninvasive monitoring for titrating therapy Prioritize complex data to support action plan Improve resource utilization and maintain patient care quality by planning for future needs for institutional and regional critical care resources Use and teach medication safe practice guidelines and determine cost- effectiveness of therapeutic interventions Develop programs and change unit, institution, and regional practice to improve care of critically ill patients Develop skills of ICU nurses and ancillary personnel in caring for critically ill patients and provide in-service education Use existing tool sets to assess patient and family satisfaction and direct the development of new tools when appropriate Use, teach, and help enforce methods of infection control Develop programs and document improvement in patient safety monitoring and error reduction Communicate effectively with patients, families, and other involved members of the healthcare team about all treatment decisions and patient prognosis Develop high-quality relationships with other healthcare providers Continue to augment knowledge by assimilating peer-reviewed published medical literature through self-directed learning and CME activities Teach the business of medicine Diagnose and treat a sufficient number of patients with critical illness using conventional and state-of-the-art approaches to maintain clinical proficiencies Develop collaborative and productive relationships with other specialist physicians and model joint clinical planning in managing complex ICU problems Modified from Dorman T, Angood PB, Angus DC et al: Guidelines for critical care medicine training and continuing medical education Crit Care Med 2004;32(1):263–272 CHAPTER 10 Lifelong Learning in Pediatric Critical Care intensivists per the guidelines from the Society of Critical Care Medicine and includes two broad areas of learning: clinical and administrative Teaching tools should be designed and selected to optimize improvement of both physician performance and healthcare outcomes Curricular development should focus on development of effective programs that include sequenced and multifaceted activities.9 A review that evaluated 37 studies of continuing medical education activities demonstrated that the use of multiple media, a variety of instructional techniques, and exposures to content to meet instructional objectives are all needed to improve clinical outcomes.35 A recent review of teaching techniques in critical care demonstrates the importance and benefit of multiple interactive strategies that apply principles of adult learning.36,37 The practice of medicine is evolving at a rapid pace, and teaching strategies must also continue to evolve While bedside teaching and didactic lectures are important, innovative strategies are needed to maximize education in the current era For example, debriefing is a teaching strategy that is integrated into simulationbased education and is increasingly being used within the context of clinical care in the ICU to teach important principles A debrief is a review of a situation led by an experienced facilitator to allow learners to explore steps that went well and identify opportunities for improvement and learning.38 A survey of PCCM program directors demonstrated that faculty role modeling is the most common technique used in pediatric critical care programs to teach the competencies of professionalism and communication.39 Bedside Teaching In 1964, Reichsman et al demonstrated a 75% “incidence” of teaching at the bedside during attending rounds.40 That number had declined to 16% in 197841 and may be lower today Little data exist on the frequency of bedside teaching in the ICU in the modern era of medical education Experiential learning and casebased learning at the bedside (both of which are based on principles of adult learning) are traditionally thought to be the most effective means of educating clinicians in the understanding of disease processes and evaluation and management of critically ill patients The impact of experiential learning at the bedside caring for a patient with septic shock and multiorgan dysfunction is extremely valuable and difficult to quantify Less dramatic but potentially equally effective are instances when one palpates a thrill, hears a gallop, feels an enlarged liver or spleen, listens to wheezing or stridor, or performs a detailed neurologic examination in a patient who has experienced a stroke or a spinal cord injury Medical technology can be leveraged to enhance bedside teaching, as when flow-volume loops in a child with asthma are used to teach the principles of mechanical ventilation in the setting of bronchospasm, or the waveforms on bedside monitors allow a demonstration of the impact of ventilation on hemodynamics Showing learners extracorporeal membrane oxygenation circuits, continuous venovenous hemodialysis and ultrafiltration machines, high-frequency ventilators, and ventricular assist devices while they are being used in patient care reinforces prior learning and may provide the “a-ha!” moment that is difficult to recreate in didactic lectures In addition, when trainees present the historical data and physical findings of their patients to the attending physician and the team during bedside rounds, they can be taught to describe the information relating to their patients in a succinct manner and discriminate between important and less important information, develop a list of differential diagnoses, and formulate a treatment plan Bedside and experiential learning teaches the 71 important skill of thinking on one’s feet, which will assist in drawing correct conclusions regarding diagnosis and making management decisions Bedside teaching and rounds are also important for the demonstration and role modeling of professionalism It is important to remember that patients are often the best teachers, and developing into an outstanding practitioner hinges on exposure to a large and varied number of clinical situations to develop all of the domains of competency Procedural Training Procedural expertise is crucial in the care of critically ill children Specific skills that must be acquired during fellowship include peripheral arterial and venous catheterization, central venous catheterization, endotracheal intubation, thoracostomy tube placement, and procedural sedation.42 In addition, knowledge of the indications, technique, limitations, and complications of other procedures—including cricothyroidotomy, tracheostomy, pericardiocentesis, and abdominal paracentesis—is recommended.12,43,44 There are a wide range of approaches to teaching procedures, which include didactics, video and web-based training, and simulation Regardless of the specific techniques implemented, initial performance under direct supervision is paramount, with progressive development of autonomy through the course of fellowship training A recent single-center study demonstrated a statistically significant decrease in the number of central lines and arterial lines performed by PCCM fellowship trainees over the past 10 years.45 While medical advances in recent years have allowed for less invasive forms of interventions, it is critical that educators assess the potential impact of fewer procedures to ensure competency of those in the field.45 Simulation Training Simulation training is an interactive technique used to replicate real-world situations and experiences.46 Modern medical simulation originated in the early 1960s with simple resuscitation manikins that were used in the field of anesthesiology; this technique has both expanded and evolved substantially over time Technological advances in computer programming and manikin development as well as increased affordability have contributed to increasing use of this educational modality.47 For all levels of learners, simulation is a valuable educational modality for critical care.48 Medical simulation can be generally divided into five different categories: role-play, standardized patients, partial task trainers, computerized patients, and electronic patients The most comprehensive form of simulation training is the electronic patient or high-fidelity, instructor-driven manikin.46 These manikins are programmed to display normal and abnormal physical examination findings The training session is divided into three sections: prebriefing, scenario exercise, and debriefing Debriefing plays an important role in the educational process, allowing the instructor to reemphasize the objectives of the exercise and address knowledge gaps that may have been unmasked during the scenario Debriefing also allows the trainees to reflect on performance and discuss areas for improvement.49–52 Simulation training in medical education has gained widespread acceptance as a result of the ease of simulating critical events, safety of the learning environment, and reproducibility of the clinical scenarios.53 Learners practice and develop skills without the consequences of negative patient outcomes For procedures that are performed infrequently, simulation allows repeated opportunities to practice Scenarios can be created to simulate a 72 S E C T I O N I Pediatirc Critical Care: The Discipline range of complications that the learner might otherwise not witness or experience Evidence demonstrates that learners enjoy participation in medical simulation, and individual and team member performance is enhanced In addition, self-confidence, knowledge, and operational performance improve with simulation training.54–57 Simulation-based medical education with deliberate practice to attain constant skill improvement is superior to traditional clinical education for acquisition of a wide range of medical skills.58 Some centers have implemented intense simulation-based orientation training for first-year pediatric critical care medicine fellows In addition to procedural skill improvement, simulation has been used to facilitate education in communication involving difficult conversations and end-of-life care.59,60 The ICU is a highly dynamic setting with complex patients and frequent high-risk situations and invasive procedures that need a well-functioning multidisciplinary team In situ portable simulation provides the added advantage of replicating the true working environment of the ICU The learners are placed in the patient care setting and have the opportunity to use the actual equipment within the environment in which they work In situ simulation has been used to identify safety threats and reinforce resource location and teamwork behaviors.61 It allows multidisciplinary team training in the setting of their clinical work.62 Highfidelity simulations using multidisciplinary teams in the ICU have been linked to improvements in teamwork and efficiency as well as improved times to initiate key clinical tasks during resuscitation.63 In addition to improving teamwork, in the extracorporeal membrane oxygenation literature, a high-fidelity simulation curriculum among PICU personnel showed significantly improved times for response to emergencies, including changing the oxygenator and managing air embolisms.64 From the traditional code team to the performance of highrisk procedures, personnel must work together to accomplish many tasks Training in teamwork and communication, known as crew (or crisis) resource management (CRM), was developed and implemented in the aviation industry to reduce or eliminate the contribution of human errors to catastrophic events These principles have been adapted for use in anesthesia crisis management protocols and focus on competent team management, dynamic decision-making, interpersonal behavior, situational awareness, effective use of resources, and stress management.65 CRM training improves team functioning and dynamics in pediatric intensive care settings.66–68 Clinical skills acquired during medical simulation have been shown to directly improve patient care practices and may improve patient outcomes.53 Additional studies are needed to identify the optimal modality, frequency of exposure, quality of assessment tools, and impact of simulation education on patient care A multicenter pediatric network (International Network for Simulation-based Innovation, Research, and Education) has been formed to measure the impact of simulation on clinical outcomes Despite some limitations, simulation training remains an important adjunct to traditional medical education in the ICU Beyond Graduate Medical Education Continuing Medical Education, Board Certification, and Maintenance of Certification The speed of medical and technological advancement makes ongoing education for those who have completed formal training paramount Education for physicians practicing in the clinical environment falls under the umbrella of Continuing Medical Education (CME), which is designed to promote the knowledge, skills, and ongoing performance of physicians.69 CME requirements are locally managed at the institutional level, and also are determined and monitored by state licensing boards Many states set specific standards for the amount of CME credit required annually for all licensed physicians.70 Individual institutions, private agencies, and the American Academy of Pediatrics offer CME activities to fulfill these requirements States may also require additional education; in some states, physicians are required to complete additional pain management or opiate prescribing education Traditionally, methods of delivering CME for physicians involve didactic experiences, such as grand rounds or other lecture series It is reasonable to question whether these experiences are sufficient to drive outcomes in physician knowledge, practice, and—most important—patient-centered outcomes Furthermore, evidence suggests that physicians, like all learners, are unreliable self-assessors,71 highlighting the need for external review to produce and ensure learning outcomes Board certification and maintenance of certification complements GME and CME in certifying practitioners in standards of excellence, which are intended to lead to high-quality health outcomes for their patients Accreditation boards such as the American Board of Pediatrics72 primarily serve the public, ensuring that physicians participate in recertification through retesting and maintenance of certification activities The required elements for the education and training of pediatric intensivists in patient care have been defined over time and continue to evolve The ABP and the subboard of Pediatric Critical Care Medicine have developed a list of content specifications for the subspecialty examination.43 While this list is not intended to serve as a curriculum, the pediatric intensivist sitting for the examination is expected to be familiar with the wide range of topics covered by the content specification document The content outline is available at https://www.abp.org/sites/abp/files/ pdf/critical_care_content_outline.pdf To qualify for the ABP subspecialty examination, applicants are required to have a valid unrestricted allopathic and/or osteopathic license to practice, initial certification in general pediatrics, and successful completion of critical care medicine training in a program accredited by the ACGME The applicant must also provide evidence of meaningful scholarship during training, which can include research, an educational project, or a quality project Following initial certification, the Maintenance of Certification (MOC) program ensures that the intensivist invests in ongoing knowledge and skills necessary for the delivery of quality care MOC is based on the six competency domains that are evaluated during fellowship training and includes four parts: professional standing (medical license), lifelong learning and self-assessment, passing an examination, and performance in practice with participation in ABP-approved quality improvement activities in patient care MOC has evolved with time Following an extensive evaluation and an international meeting devoted to the “Future of Education in Pediatrics,” MOCA-Peds, an ongoing assessment tool that replaces the intermittent MOC examination, was developed It is currently active in general pediatrics and being rolled out to subspecialties Although medical knowledge may be assessed through standardized testing, it is unclear whether this or other activities for certification truly lead to improved patient outcomes To achieve this goal, the medical community must prioritize practice-based improvement activities and experiences that incorporate adult learning principles, are highly relevant to the learner, and require CHAPTER 10 Lifelong Learning in Pediatric Critical Care active participation Additionally, they must be authentic on a local level, addressing local problems and opportunities Organizations can actively incorporate CME/MOC activities into daily workflow for flexible, real-time learning and assessment Several activities currently available allow physicians to receive both CME and MOC credit The end of formal training as a fellow represents the beginning of a lifelong process of refining one’s knowledge and judgment, constituting the essence of professional development and maintenance of competency While the medical profession and society at large have historically assumed physician proficiency by virtue of their continued practice, it is dangerous to assume that longevity is tantamount to expertise Instead, mature clinicians reflect on their daily medical experiences to place them in a larger context of previous encounters, critically evaluate their own performance, acknowledging both effective and ineffective aspects of patient care, and seek to fill in gaps in knowledge or performance.52,56 Critical care is practiced in an atmosphere of innate uncertainty In this environment, the practicing intensivist must be able to adapt in real time and, once a situation is resolved, to step back and pursue generalizable knowledge for the next encounter Another aspect of lifelong learning is the role that teaching plays in ongoing self-directed learning By reviewing and synthesizing contemporary literature, whether for a didactic lecture for the learner or for family and patient information, the seasoned intensivist creates an opportunity to address all aspects of professional development New Methods of Assessment and Future Challenges Educators and those responsible for certification at all levels are currently actively engaged in discussion of new methods and concepts of assessment There is a growing appreciation for the value in multiple low-stakes assessments that include rich narrative feedback73 and the integration of these assessments into a composite whole Formative and summative assessment occurs along a spectrum instead of at discrete points in time Innovations in higher-stakes testing assessment are occurring in all phases of the test development cycle, including design and implementation of items and tests (assessment engineering, automated item generation); items and tasks used within the test (game-based assessment, computer-based simulations, use of Internet or key online resources during a test, and alternative test item types, such as drag-and-drop or multiple correct answers); item selection during the test (computer-adaptive testing); and delivery of the test (online proctoring versus test center proctoring vs no proctoring) The rapid development of computer and Internet technology makes innovation inevitable; the resulting change needs to be managed carefully, with an eye to testing validity and reliability as well as test taker approval Although beyond the scope of this chapter, we would be remiss to not mention factors such as the advent of the electronic health record, compensation and billing requirements, collaborative 73 learning through social media communities (e.g., #PedsICU)74 and faculty-driven care, which have undeniably impacted the learning environment Students, residents, and fellows have very different opportunities for learning and experiences relative to those in the past More opportunities for hands-on care by faculty and closer supervision of learners at all levels most likely are better for individual patients, but they may not provide some of the most powerful learning experiences of past eras Even documentation experience may be limited—in some settings, students are not permitted to document patient information in the electronic health record, raising questions about their opportunities to write notes and, more important, organize their thoughts into coherent patient assessments and plans Intensivists and physicians in general must be attuned to environmental and technological advances, which change practices and the ways that they teach, practice, and learn Key References Accreditation Council for Graduate Medical Education Common program requirements Available at: http://www.acgme.org/Portals/0/PDFs/ Nasca-Community/Section-VI-Memo-3-10-17.pdf ?ver5201703-10-083926-603 Bilmoria KY, Chung JW, Hedges LV et al National cluster-randomized trial of duty-hour flexibility in surgical training N Engl J Med February 25, 2016;374(8):713-727 Carraccio CL, Benson BJ, Nixon LJ, Derstine PL From the educational bench to the clinical bedside: translating the dreyfus developmental model to the learning of clinical skills Acad Med 2008; 83:761-767 Cheng A, Hunt EA, Donoghue A, et al Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial JAMA Pediatrics 2013;167:528-536 Cook DA, Hatala R, Brydges R, et al Technology-enhanced simulation for health professions education: a systematic review and metaanalysis JAMA 2011;306:978-988 Davis DA, Mazmanian PE, Fordis M, et al Accuracy of physician self-assessment compared with observed measures of competence: a systematic review JAMA 2006;296:1094-1102 Dormon T, Angood PB, Angus DC, et al Guidelines for critical care medicine training and continuing medical education Crit Care Med 2004;32(1):263-272 Engorn BM, Newth CJL, Klein MJ, et al Declining procedures by pediatric critical care medicine fellowship trainees Front Pediatr 2018; 6:365 Knowles M Self-Directed Learning Chicago: Follet; 1975 Nasca TJ, Philibert I, Brigham T, Flynn TC The next graduate medical education accreditation system: rationale and benefits N Engl J Med 2012;366(11):1051-1056 Silber JH, Bellini LM, Shea JA, et al Patient safety outcomes under flexible and standard resident duty-hour rules N Engl J Med 2019; 380(10):905-914 Tainter CR, Wong NL, Bittner EA Innovative strategies in critical care education J Crit Care 2015;30(3):550-556 The full reference list for this chapter is available at ExpertConsult.com ... ABP subspecialty examination, applicants are required to have a valid unrestricted allopathic and/or osteopathic license to practice, initial certification in general pediatrics, and successful... through standardized testing, it is unclear whether this or other activities for certification truly lead to improved patient outcomes To achieve this goal, the medical community must prioritize... good relationships with other healthcare providers Identify and initiate discussions involving ethical issues and parents/patients’ wishes in making treatment decisions using advance directives