The Academic Half-Day redesigned: Improving generalism, promoting CanMEDS and developing self-directed learners

Abstract

BACKGROUND:

The Montreal Children’s Hospital Pediatric Residency Program redesigned its Academic Half-Day based on program concerns consistent with the published literature. These concerns included inadequate preparation for general paediatric practice, gaps in CanMEDS education and exclusive use of didactic lectures. Novel instructional methods included monthly simulation sessions to learn CanMEDS competencies, increased use of general paediatricians as instructors, implementation of a ‘systems-based’ curriculum and development of self-directed learning skills through activities such as ‘Residents as Teachers’.

METHOD:

A postimplementation online survey was sent to all 18 residents who had been exposed to both curricula. The survey was designed to determine the impact of the new curriculum on their perceived ability to retain information and acquire the competencies of a general paediatrician, and to assess the effect on their self-directed learning. Responses were recorded on a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’.

RESULTS:

Fourteen of 18 (78%) residents completed the survey. All residents preferred the ‘systems-based’ educational program. Seventy-nine percent of all residents agreed that the simulation sessions were an effective method of learning the CanMEDS competencies. Importantly, 64% of residents voluntarily read more about the topics presented and 71% agreed that they retained the content better. Moreover, 79% believed that changes made to the teaching curriculum better prepared them for a general paediatric practice and 64% of residents believed that it better ‘supplements’ learning in the clinical setting.

CONCLUSION:

The authors propose that the new curriculum is comprehensive, while developing the skills required for life-long learning as a general paediatrician.

Paediatric residency programs must support residents to acquire the knowledge and develop the skills necessary to provide care for the paediatric population. In an era in which the epidemiology of childhood disease is changing, programs may not be meeting the needs of the trainees or the society they serve. Residents are expected to obtain the necessary skills to care for patients with more complex needs, while learning and integrating a rapidly expanding scientific knowledge base (1,2). Simultaneously, they are training in a milieu characterized by reduced clinical working hours (3).

The Royal College of Physicians and Surgeons of Canada (RCPSC) mandates resident training programs to incorporate the teaching and assessment of the CanMEDs roles with a mission “to maintain the highest standards in specialty medical education and professional practice” (4). Paediatric residents have outlined several deficiencies in their learning of these important competencies (4,5). Additionally, despite efforts to improve residency training, American and Canadian paediatric residents repeatedly report deficiencies in community- and ambulatory-based teaching of general paediatrics (6–8). Part of the issue may be the formalized regular weekly Academic Half-Days (AHDs) used to complement clinical teaching, which is generally “variable, unpredictable and lacks continuity” (9).

Novel educational strategies may prove useful to better prepare residents for clinical practice as competent general paediatricians. One method is self-directed learning (SDL), a process in which individuals take the initiative in identifying their learning needs, setting learning goals, finding resources, implementing learning strategies and evaluating learning outcomes. This method has been shown to improve learning and may also enhance future physician performance (10–12). Simulation is another technique that has become commonly used (13), and learners have demonstrated improved retention of knowledge and skills in Resuscitation/Crisis Resource Management (CRM) as well as procedural skills training (13,14). Opportunities to learn the Intrinsic CanMEDS roles (15) (Figure 1) through simulation exist but are less frequently reported. Finally, to keep with the paradigm shift in medical education from ‘assessment of learning’ to ‘assessment for learning’ (16), formative assessment sessions may be viewed as an important educational strategy during residency.

Figure 1).

CanMeds Framework (30). Copyright © 2005 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Reproduced with permission. Intrinsic CanMEDs roles: Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional.

Our objective was to investigate whether a novel paediatric residency educational curriculum improved self-directed learning and perceived learning on the part of the learner. Our curriculum is characterized by a multimodal approach with ‘Resident as Teacher’ programs, increased focus on formative assessment and the use of simulation to learn all of the CanMEDS competencies.

METHODS

Setting

The Montreal Children’s Hospital Pediatric Residency Program comprises a ‘core’ three-year training program with approximately 30 residents based in a tertiary care hospital. Residency training involves clinical rotations of four to six weeks on the general paediatric ward, critical care settings (neonatal and paediatric), subspecialty rotations and community-based clinics.

Needs assessment

The teaching schedule was organized as a 4 h AHD once per week. In 2008, residents, as well as the residency training program oversight committee comprising hospital-based and community-based paediatricians, had outlined concerns regarding the teaching program and content. Similar to many programs, the established curriculum was predominantly based on the use of didactic lectures (ie, learners were passive). It consisted of ‘volunteer’ instructors who presented on ‘opportunistic topics’, frequently based on the interests of the available instructors. Sessions were commonly repeated within a three-year period. Given the increased availability of paediatric subspecialists who are normally employed in a tertiary care centre, the emphasis of instruction was on the subspecialist’s approach rather than that of a generalist. Finally, there was little organized to longitudinally prepare residents for the RCPSC General Pediatrics Examination.

New teaching opportunities arose in 2008 when the Pediatric Specialty Committee of the RCPSC revised their educational Objectives of Training for Pediatrics (17) and the new McGill Medical Simulation Centre (Montreal, Quebec) was opened. The Simulation Centre enabled residents to learn in a safe and authentic learning environment without the risk of harm to patients.

Curriculum development

The teaching curriculum was transformed in July 2009 using the six-step model proposed by Kern et al (18). After reviewing the literature, areas of improvement were identified by the Residents Training Committee, comprising general paediatricians, paediatric subspecialists and paediatric residents (5–7). The goals and objectives were formulated according to the RCPSC Objectives and were refined by the chief residents, staff responsible for AHD and program director, and vetted through the Residents Training Committee. The educational strategies were chosen based on educational goals and, finally, implementation and evaluation of the new curriculum was performed. Teaching within this new curriculum was based on key principles described by Parsell and Bligh (19). These concepts include teaching to the learners’ needs, encouraging independent learning and reflection, and varying the teaching methods in different contexts, ie, interactive simulation sessions, case presentations and clinical scenarios.

The ‘new’ curriculum was reorganized on a monthly systems-based schedule, with each system repeated twice within a three-year period, but with no repetition of content. Division directors, rather than individual instructors, were approached and given the responsibility to assign clinical teachers to particular topics using the RCPSC Objectives of Training in Pediatrics. Instructors were asked to at least minimize, if not eliminate, the use of didactic lectures, and incorporate hospital-based and community-based clinical scenarios in which residents could be more engaged as active learners. General paediatricians, both hospital-based and community-based, were recruited as instructors to provide proper focus for general paediatric residents. Teaching is generally valued at the institution. Coupling this model with a financial remuneration that rewards ‘nonclinical’ activities also helped to fulfil the requirement for teachers, including general paediatricians.

The AHD was divided into various segments as per Appendix 1. The first hour was a resident-led ‘case of the week’, an interesting case presented to promote clinical reasoning among audience members. This ‘case of the week’ was adopted from the former curriculum. Following this, the resident was exposed to a series of interactive lectures based on clinical scenarios. The learners were expected to remain engaged throughout the session by participating and answering questions. The final session of the day included a ‘Residents as Teacher’ session, supervised by a clinical staff instructor. These practical sessions included a preassigned resident teaching a practical approach to a topic as in Table 1.

TABLE 1.

Two-block teaching timetable

Block 1: Cardiovascular system	Case of the week	Interactive sessions	Resident as teacher
Week 1		Approach to arrhythmias	Electrocardiography
Week 2		Cardiac physiology	Cardiac interpretation of chest radiograph
Week 3		Approach to syncope	Defibrillators
Week 4		Approach to murmurs	Electrocardiography
Block 2: Respiratory system	Case of the week	Interactive sessions	Resident as teacher
Week 1		Approach to cough	Chest radiography
Week 2		Respiratory physiology	Pulmonary function test
Week 3		Approach to cystic fibrosis	Sleep studies
Week 4		Approach to asthma	Interpretation of pleural fluid

Case of the Week: A resident chose a challenging patient-case scenario in which the goal was to develop clinical reasoning skills. Interactive techniques were used to stimulate discussion and teach appropriate focused history-taking, physical examination and differential diagnosis skills. The session is resident-led, resident-centred and facilitated by staff. Communication was promoted between group leader and learners, enabling residents to express themselves in a safe learning environment. Interactive Sessions: These were smaller group sessions comprised of residents and one community-based or hospital-based physician. These were usually based on cases as a method of teaching a topic. ‘Residents as Teacher’: Residents were provided an umbrella topic and were responsible for finding specific teaching objectives. These sessions followed the Self-Directed Learning principle; residents took the initiative to identify their learning needs by selecting their own topic, they set the learning goals for that session and they found the resources they needed to prepare to teach the topic. The following are examples of sessions: reading chest radiographs or pulmonary function tests during the pulmonary module; and electrocardiograms during the cardiology module

The Simulation Centre was used to incorporate monthly simulation workshops focusing on the intrinsic CanMEDS roles. In addition to the simulation sessions commonly implemented at other institutions, such as crisis resource management, medical expert assessment and to practice communication skills, the authors believed simulation would also provide added value in teaching other intrinsic CanMEDS roles. For example, simulation was used in a novel manner to help residents improve their own teaching (scholar), learn how to manage conflict (communicator, collaborator, professional) and learn how to handle challenging ethical situations (communicator, collaborator, health advocate, professional). A member of the Residents Training Committee led this initiative, selecting scenarios based on Royal College Objectives and ensuring that content did not repeat. The instructors who developed and facilitated the high-fidelity scenarios were general paediatricians and paediatric subspecialists formally trained in CRM education through simulation and debriefing. At the time of the study, these scenarios were held at the Simulation Centre during AHD for residents only, and were changed to interprofessional scenarios since study completion.

Finally, formative assessment sessions were incorporated to promote active learning. These sessions included Observed Structured Clinical Encounters (OSCE) with embedded CRM scenarios because this was an area of concern for paediatric residents (16,20), and formative multiple choice question sessions, based on the systems-based teaching modules.

Evaluation of the incorporated changes

A postimplementation online survey was sent to all 18 second-, third- and fourth-year paediatric residents who had participated in both the ‘old’ and ‘new’ curricula. These residents were exposed to the new curriculum for 12 months before completing the survey. The eight-question survey was designed to determine the impact of the updated curriculum on their ability to retain information, acquire competencies of a general paediatrician and to assess the effect on their self-directed learning. Responses were recorded on a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’.

RESULTS

Fourteen of the 18 residents who were exposed to both curricula completed the survey (78%) and their characteristics are outlined in Table 2. All residents who responded preferred the ‘systems-based’ schedule. Seventy-nine percent of the residents agreed that the simulation sessions were an effective method to learn the CanMEDS competencies. Importantly, 64% of residents voluntarily read more about the topics presented and 71% agreed they better retained the content compared with the old curriculum. Moreover, 79% believed that changes made to the teaching curriculum better supported a general paediatric practice. Finally, 64% of residents believed that the new curriculum better supplemented their learning in the clinical setting.

TABLE 2.

Demographic characteristics of paediatric residents included in the survey

Characteristic	n (%)
Sex
Female	9 (60)
Male	5 (40)
Training level
Second year	5 (35.7)
Third year	6 (42.9)
Fourth year	3 (21.4)

DISCUSSION

Paediatric residents are graduating from residency programs without the necessary self-efficacy in key areas of clinical practice (5,6). It is imperative that residency programs respond and integrate innovative and more effective approaches to facilitate resident learning. Competency-based medical education, a training curriculum that focuses on resident proficiency outcomes, is on the horizon (21) and, theoretically, will address many of the outlined concerns, but has not been integrated into residency education outside of pilot projects. In the current paradigm of a ‘time-based’ model of education, our new teaching curriculum improved the quality of education as perceived by the paediatric residents, promoted the development of the competencies of a general paediatrician as outlined by the CanMEDS framework and supported the development of self-directed learners. Learners also preferred the systems-based approach to scheduling the AHD in concentrated modules.

Paediatric residency program graduates frequently report that they are inadequately prepared to practice as a general paediatrician (5,6). This reality may be explained by the emphasis placed on subspecialty clinical rotations along with subspecialists as teachers within academic educational programs of university-based hospitals (5). Our program modified the AHD to promote learning of general paediatrics. By implementing generalists in the instruction of general paediatric topics and by adhering to the RCPSC Objectives in selecting educational content, we focused on the learning needs of paediatric residents (19). These changes were perceived to have a major impact on paediatric residency training because the vast majority of residents reported that the ‘new’ curriculum better supported practice in a general paediatric environment and believed it better supplemented clinical teaching.

We implemented a simulation-based program that provided context and perhaps greater relevance to the learning of the Intrinsic CanMEDS roles. Although the implementation of the CanMEDS framework has changed residency training and made it more relevant to the needs of society, its incorporation still faces significant challenges. When the Intrinsic CanMEDS roles were incorporated into residency programs, words such as “frustrating”, “poorly defined” and “difficult” were used by residents and faculty to describe efforts (22–24). Incorporating simulation to teach the Intrinsic CanMEDS roles, with novel scenarios that included managing conflict and ethical challenges, was perceived positively by the majority of learners in our study. Simulation was also utilized in our new curriculum to support residents in learning how to manage paediatric acute care scenarios (13,14). This can provide residents with the opportunity to learn in multidisciplinary teams, help to identify human-factor errors, and modify team behaviour leading to a reduction in medical errors and improve patient outcomes (25).

Demonstration of life-long learning skills is a requirement during residency training and maintenance of certification in Canada and the United States (26); however, the didactic lectures and the predetermined nature of residency AHD inadequately equip residents with the necessary skills. Although a variety of ideas have been suggested, the literature is limited on how to effectively teach self-directed learning skills (27). Knowles (28) describes self-directed learning as a process that involves diagnosing one’s learning needs, formulating learning goals, identifying resources for learning, implementing appropriate learning strategies and evaluating learning outcomes. We used this framework to incorporate change into our ‘new’ curriculum. As an example, we retained the ‘case of the week’ session and added a ‘Resident as Teacher’ session, which are both led by residents and focused on teaching skills of the Scholar-role. Residents were expected to gain experience in critical thinking about a case or topic, and be able to clearly lead their colleagues through the session. We provided both small group discussions and simulation-based instruction on how they could improve their teaching skills, with the hope that they would focus on how to facilitate learning rather than simply on delivery of information through a lecture. These sessions, along with the other changes to the curriculum, may have accounted for the increased reading reported by the residents.

Although the new curriculum was practical and comprehensive, we did face key challenges throughout the implementation phase. First, because the tendency was for teachers to revert to ‘old’ lecture presentations, they required support to ensure that content was new and interactive. Second, it was important to create buy-in among the residents. It took time for them to understand the value of the additional preparation required before teaching. Although challenging initially, the new curriculum was perceived as a positive change by both teachers and learners, and become easier to maintain over time.

The primary limitation to our study was that our postimplementation evaluation was a survey and not an objective assessment of the learning from the incorporation of the new teaching curriculum. An ideal program evaluation would focus on higher levels of the classic pyramid described by Kirkpatrick and Kirkpatrick (29). The OSCE examination was based on the objectives of training and provided an opportunity for learners to observe how they performed across the CanMEDS roles to identify their own learning gaps. Although the present survey was subjective, we believe that it still contributes to the literature, given the paucity of data on educational innovation and its evaluation in paediatric residencies. A second limitation was that our study survey was developed and implemented at a single institution with a relatively small sample size. Our survey studied only second-, third- and fourth-year residents because these were the learners exposed to the curriculum before and after implementation. Thus, our results are limited to senior learners and cannot necessarily be generalized to first-year residents. We believe this was a necessary starting point on which other authors may build.

CONCLUSION

Learning is an essential part of a resident’s responsibilities, regardless of whether it takes place in the clinic, in the hospitals or in the classroom. Competent general paediatricians are able to incorporate the CanMEDS roles with their general paediatrics knowledge to provide optimal patient-centred care. Because clinical teaching is variable and can be challenging when the competing responsibilities of patient care take precedence, the AHD was reorganized to provide a more effective adjunct. Our survey suggests that our new curriculum may help promote the development of the skills required for a general paediatrician, and may motivate learners to develop life-long learning skills. The curriculum provides a model that other training programs may build on to stimulate their residents to be self-directed in their learning. Further research will be required to assess the impact on resident performance.