Su Ting T Li

Successful self-directed lifelong learning in medicine: A conceptual model derived from qualitative analysis of a national survey of pediatric residents

Purpose Self-directed lifelong learning is integral to medical professionalism, yet how best to encourage its development during clinically intensive training is unknown. The authors develop a model for successful self-directed learning by analyzing qualitative data from a national survey of residents. Method Pediatric and medicine/pediatric residents at 46 training programs completed a Web-based survey in 2008–2009. Self-reported barriers to and strategies for achieving self-directed learning goals were systematically analyzed through inductive iterative review. Results A total of 992 out of 1,739 (57%) residents responded. Barriers to achieving self-directed learning goals were categorized into difficulty with personal reflection, environmental strain, competing demands, difficulty with goal generation, and problems with plan development and implementation. Strategies for achieving learning goals included creating goals that were important (relevant to the learner and prioritized by the learner as important to achieve), specific (with broad goals broken down into incremental steps and a specific plan for each step), measurable, accountable (with reminder and tracking systems and building in internal and external accountability), realistic (achievable goals which utilize existing opportunities and constant self-adjustment), and included a timeline for completing the goal (and incorporating the goal into their daily routine). Conclusions On the basis of the data, the authors propose a conceptual model for self-directed lifelong learning involving creation of learning goals and plan development based on individual reflection and self-assessment, and continual revision of goals and/or plans based on degree of goal attainment. This model could be broadly applicable throughout medical education.

Factors associated with successful self-directed learning using individualized learning plans during pediatric residency.

OBJECTIVE The aim of this study was to determine whether resident or program characteristics are associated with effective self-directed learning of residents. METHODS A cross-sectional survey of pediatric and medicine/pediatric residents and program directors from a nationally representative sample of residency programs was conducted. Self-directed learning efficacy was measured by resident-reported progress on learning goals from their most recent individualized learning plan (ILP). Multilevel linear regression models were used to analyze the relationship between learner and program characteristics and self-directed learning efficacy of residents. RESULTS All program directors of participating programs (N = 46) completed the survey; the response rate from residents was 57% (992/1739). At the time of the survey, 78% of residents had previously written an ILP. Most residents achieved moderate self-directed learning efficacy. The most important factors associated with greater self-directed learning efficacy included using a system to track ones own progress in achieving learning goals, higher score on a propensity toward lifelong learning scale, and reporting greater confidence in self-directed learning abilities. Program characteristics, including program-level support for ILPs, had little or mixed association with resident self-directed learning efficacy. CONCLUSIONS The most important factors associated with effective self-directed learning were resident characteristics. Our findings imply that residency programs should invest their limited resources in curricula that help residents develop measurable goals and systems for tracking progress toward goal attainment. Since propensity toward lifelong learning was an important factor, medical schools and residency training programs should enhance their efforts to develop this characteristic in learners.

A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications

Abstract Telepsychiatry (TP; video; synchronous) is effective, well received and a standard way to practice. Best practices in TP education, but not its desired outcomes, have been published. This paper proposes competencies for trainees and clinicians, with TP situated within the broader landscape of e-mental health (e-MH) care. TP competencies are organized using the US Accreditation Council of Graduate Medical Education framework, with input from the CanMEDS framework. Teaching and assessment methods are aligned with target competencies, learning contexts, and evaluation options. Case examples help to apply concepts to clinical and institutional contexts. Competencies can be identified, measured and evaluated. Novice or advanced beginner, competent/proficient, and expert levels were outlined. Andragogical (i.e. pedagogical) methods are used in clinical care, seminar, and other educational contexts. Cross-sectional and longitudinal evaluation using quantitative and qualitative measures promotes skills development via iterative feedback from patients, trainees, and faculty staff. TP and e-MH care significantly overlap, such that institutional leaders may use a common approach for change management and an e-platform to prioritize resources. TP training and assessment methods need to be implemented and evaluated. Institutional approaches to patient care, education, faculty development, and funding also need to be studied.

Attributes of residents as teachers and role models-A mixed methods study of stakeholders

Background: Residents are at the forefront of student education in the hospital, yet valid tools to assess their performance as teachers are lacking. Aims: To develop a valid evaluation tool for assessing resident performance as educators for clerkship students. Method: A mixed-methods design was used. Focus groups of residents and medical students explored desired behaviors in resident educators. Using grounded theory, a list of behaviors was generated inductively through iterative review and categorized into themes. After thematic saturation, behaviors were rated on a Likert scale by stakeholders based on “importance” and “accuracy of measurement.” Items which were both important and accurate were used in the final tool. Results: Eighty-five desirable behaviors for resident educators were identified and consolidated into a 14-item tool. Twenty met both “importance” and “accuracy” criteria and fell under themes of respect, safe environment, balancing supervision with autonomy, relevant teaching and feedback. Nineteen “important” behaviors deemed not accurately measurable fell under themes of professionalism, communication, management skills and leadership. Conclusions: Evaluation of residents as teachers and development of resident-as-teacher curricula should emphasize aforementioned areas. Professionalism and organizational skills may not be measurable reliably by learners. Complementary tools to assess these aspects of resident performance are necessary.

Individualized Learning Plans: Basics and Beyond

From the Department of Pediatrics, University of California, Davis, Sacramento, Calif (Dr Li); and Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke) Dr Burke is the president of the Association of Pediatric Program Directors. Address correspondence to Su-Ting T. Li, MD, MPH, 2516 Stockton Blvd, Sacramento, California 95817. (e-mail: su-ting.li@ucdmc.ucdavis. edu).

Research training among pediatric residency programs: a national assessment.

Purpose The Accreditation Council for Graduate Medical Education (ACGME) states that “residents should participate in scholarly activity.” However, there is little guidance for effectively integrating scholarly activity into residency. This study was conducted to understand how pediatric residency programs meet ACGME requirements and to identify characteristics of successful programs. Method The authors conducted an online cross-sectional survey of all pediatric residency program directors in October 2012, assessing program characteristics, resident participation in scholarly activity, program infrastructure, barriers, and outcomes. Multivariate logistic regression was used to identify characteristics of programs in the top quartile for resident scholarly activity participation. Results The response rate was 52.8% (105/199 programs). Seventy-seven (78.6%) programs required scholarly activity, although definitions were variable. When including only original research, systematic reviews or meta-analyses, and case reports or series with references, resident participation averaged 56% (range 0%–100%). Characteristics associated with high-participation programs included a scholarly activity requirement (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 1.03–30.0); program director belief that all residents should present work regionally or nationally (OR = 4.7, 95% CI = 1.5–15.1); and mentorship by >25% of faculty (OR = 3.6, CI = 1.2–11.4). Only 47.1% (41) of program directors were satisfied with resident participation, and only 30.7% (27) were satisfied with the quality of research training provided. Conclusions The findings suggest that resident scholarly activity experience is highly variable and suboptimal. Identifying characteristics of successful programs can improve the resident research training experience.

Increasing Scholarly Activity Productivity During Residency: A Systematic Review

Purpose Although resident participation in scholarly activity is mandated by the Accreditation Council for Graduate Medical Education, programmatic factors associated with success are not defined. This systematic review’s objective was to determine which interventions are effective in increasing resident scholarly activity productivity (RSAP), as measured by participation in scholarly activity, presentations, or publications. Method The PubMed, MEDLINE, Cochrane Library of Systematic Reviews, PsycINFO, CINAHL, and ERIC databases were searched through October 2013. English-language articles evaluating interventions to increase RSAP in U.S. or Canadian residency programs were included, without date limits. Two independent reviewers selected articles for inclusion and extracted data. Discrepancies were resolved by consensus. Results Of the 6,248 records screened, 80 studies underwent data abstraction. Twenty-six described outcomes without a comparison group, leaving 54 studies representing 13 medical and surgical specialties. Interventions included required scholarly activity participation, protected research time, research curricula, research directors, dedicated research days, and research tracks. Focusing on the 35 studies reporting statistical analysis, RSAP was associated with all interventions. There were some differences in intervention effectiveness between medical and surgical specialties. Conclusions Interventions, including protected time, research curricula, or specialized research tracks, generally result in increased participation in scholarly activity in residency programs, with mixed effects on resident presentations or publications. In many studies, interventions were bundled, suggesting that programs may need to provide increased structure and rigor through multiple pathways. The findings highlight the need for a clear definition of resident scholarly activity success aligned specifically to individual program and resident aims.

Is Residents' Progress on Individualized Learning Plans Related to the Type of Learning Goal Set?

Purpose To determine the types of learning goals residents select for their individualized learning plans (ILPs) and the relationship between goal type and progress toward achieving that goal. Method Pediatric and combined pediatric residents at 46 U.S. training programs completed a Web-based survey on ILPs in 2008–2009, describing their most important learning goal and the goals on which they made the most and least progress. Using iterative inductive review, responses were categorized into seven types (six corresponding with the Accreditation Council for Graduate Medical Education general competencies). Descriptive statistics and regression models were used to assess the relationship between goal type and progress made. Results Of 1,739 eligible residents, 992 (57%) completed the survey; 668 (38%) had previously completed an ILP and described their learning goals. Residents were more likely to report medical knowledge (MK) (53.7%) and patient care (PC) (25.9%) goals as most important and less likely to report professionalism (1.5%) and systems-based practice (SBP) (1.0%) goals as most important. Compared with progress on MK goals, residents reported significantly greater progress on PC (odds ratio [OR]: 2.20; 95% confidence interval [CI]: 1.57–3.09) and practice-based learning and improvement teaching (OR: 2.99; 95% CI: 1.59–5.63) goals and less progress on SBP goals (OR: 0.16; 95% CI: 0.05–0.56). Conclusions Residents most commonly identified MK and PC learning goals as the most important. Residents made more progress on goals related to everyday tasks, such as PC and teaching, compared with goals less integrated in everyday training, such as SBP.

In pursuit of meaningful use of learning goals in residency: A qualitative study of pediatric residents

Purpose Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study’s purpose was to elicit residents’ perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency. Method Resident focus groups and program director interviews were conducted in 2012–2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory. Results Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through. Conclusions Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

AIM To investigate the diagnostic yield, therapeutic efficacy, and rate of adverse events related to flexible fiberoptic bronchoscopy (FFB) in critically ill children. METHODS We searched PubMed, SCOPUS, OVID, and EMBASE databases through July 2014 for English language publications studying FFB performed in the intensive care unit in children < 18 years old. We identified 666 studies, of which 89 full-text studies were screened for further review. Two reviewers independently determined that 27 of these studies met inclusion criteria and extracted data. We examined the diagnostic yield of FFB among upper and lower airway evaluations, as well as the utility of bronchoalveolar lavage (BAL). RESULTS We found that FFB led to a change in medical management in 28.9% (range 21.9%-69.2%) of critically ill children. The diagnostic yield of FFB was 82% (range 45.2%-100%). Infectious organisms were identified in 25.7% (17.6%-75%) of BALs performed, resulting in a change of antimicrobial management in 19.1% (range: 12.2%-75%). FFB successfully re-expanded atelectasis or removed mucus plugs in 60.3% (range: 23.8%-100%) of patients with atelectasis. Adverse events were reported in 12.9% (range: 0.5%-71.4%) of patients. The most common adverse effects of FFB were transient hypotension, hypoxia and/or bradycardia that resolved with minimal intervention, such as oxygen supplementation or removal of the bronchoscope. Serious adverse events were uncommon; 2.1% of adverse events required intervention such as bag-mask ventilation or intubation and atropine for hypoxia and bradycardia, normal saline boluses for hypotension, or lavage and suctioning for hemorrhage. CONCLUSION FFB is safe and effective for diagnostic and therapeutic use in critically ill pediatric patients.