Pediatric emergency medicine fellowship training: A survey of program directors

Correspondence PEDIATRIC EMERGENCYMEDICINE FELLOWSHIPTRAINING: A SURVEYOF PROGRAMDIRECTORS To the Editor:--With the growth of the subspecialty of pediatric emergency medicine (PEM) in the 1980s, the number of fellowship training programs in the United States and Canada has increased substantially. The general goals and objectives of fellowship training have been established by the Curriculum Subcommittee of the Section of Emergency Medicine of the American Academy of Pediatrics} but do not intend to specify the methods to be used by the training programs. We surveyed training program directors in the United States and Canada to determine the methods used to train fellows in the acquisition of clinical, teaching, research, and administrative knowledge and skills. A 12-page, closed-ended questionnaire was mailed to all PEM fellowship training program directors in the United States and Canada in March 1994. To maximize the response rate, the questionnaire was mailed to nonrespondents in April and May 1994. The questionnaire was divided into clinical, teaching, research, and administrative skills training sections.

Demographics' of the PEM fellowship training programs. Forty-four programs responded to the survey (44 of 50; 88%). The mean emergency department (ED) census was 44,119 + 18,818 (mean + standard deviation). Forty-two programs (42 of 44; 95%) had 2-year-track fellows, whereas 6 of 44 programs (14%) had 3-year-track fellows. Clinical training. First-, second-, and third-year fellows spent a mean of 5.2 + 1.1 months in the ED. Only four of the six 3-year-track programs answered this question. During a typical ED month, fellows spent an average of 31 hours per week (range, 11 to 50) in the ED. The percentage of time that fellows spent precepting, providing direct patient care, and/or performing a combination of both is shown in Figure 1. In the 29 of 44 programs (66%) in which fellows worked overnight shifts, a mean of 3 -+ 1 overnight shifts were scheduled during a typical ED month. Of the 33 of 44 ~=26 n=21 n = 2

n=15 n=16 n = 2

n=34 n=37

n=4

100 O~

o cc

9O-

<.0

¢o 8 0

LU

70 I1)

o_ 60 i1) .E 50 I-O

"E O~

40

o ta

30

a~

20

ol

TABLE 1.

Required Electives in PEM Fellowship Training Programs Name of Elective

No of Programs (%)

Anesthesia and PICU Trauma Toxicology Orthopedics Child Abuse Ophthalmology Interhospital Transport ENT & Prehospital Care Obstetric/Gynecology and Diagnostic Radiology Pediatric Surgery and Plastic Surgery Burn Center

43 (98%) 37 (84%) 34 (77%) 33 (75%) 14 (32%) 12 (27%) 10 (23%) 9 (21%) 6 (14%) 5 (11%) 3 (7%)

ABBREVIATIONS:PICU, pediatric intensive care unit; ENT, ears, nose, and throat. programs (75%) that required fellows to do shifts as the most senior physician, 20 of 33 (60%) required first-year fellows to do such shifts. Daytime and evening shifts were scheduled in this manner in 23 of 33 (70%) and 22 of 33 (67%) programs, respectively. Twenty-eight of 33 programs (85%) scheduled fellows to work overnight shifts as the most senior physician. Twenty-four of 44 programs (54%) had a fast-track area program. Eight of the 24 programs (33%) required fellows to do shifts in this area. Paid moonlighting to fill ED shifts was required in 4 of 44 programs (9%). General goals and objectives for each elective were developed for fellows and elective directors in 14 of 44 programs (32%). All programs incorporated some required electives (Table 1). In 36 of 44 programs (81%), fellows spent an average of 11 hours per week (range, 4 to 28 hours) in the ED during an elective month. Two of 44 programs (5%) had fellows work the same number of hours per week as during a typical ED month. One program left it up to fellows when during the year they would do a prespecified number of ED shifts. Fellows did not have any clinical responsibilities in the ED in 5 of 44 programs (11%) during an elective month. Forty-three of 44 programs (98%) used regular meetings to discuss PEM-related topics. Fellows met a mean of 3 -+ 1.2 times per month to learn the knowledge base of PEM. Eighteen of 44 (41%) and 15 of 44 (34%) programs kept a record of the procedures performed by the fellows in the ED or during electives, respectively. Three of 44 programs (7%) required fellows to do a specified number of certain procedures (eg, intubations, deliveries) during electives. The PEM faculty formally evaluated fellows in 31 of 44 programs (71%). Aspects of fellowship evaluated by these programs are shown in Table 2. Fellows evaluated PEM faculty in 16 of 44 programs (36%). A written evaluation was obtained from TABLE 2. Aspects of Fellowship Training Evaluated

Aspect of Fellowship Training

No of Programs (%)

Clinical knowledge Technical and cognitive skills Teaching Interpersonal and administrative skills Research progress and EMS direction Poison center calls and leadership skills

31/31 (100%) 29/31 (94%) 28/31 (90%) 19/31 (61%) 4/31 (13%) 1/31 (3%)

lO

0 Direct Patient ;are

Precepting Only Combination of Both

FIGURE 1. Average percentage of time (with range indicated by bars) spent by PEM fellows ([~, first-year; [], second-year; [~, third-year) providing direct patient care, precepting, and/or doing a combination of both. 100

ABBREVIATION:EMS, emergency medical services.

CORRESPONDENCE

101

TABLE3.

Methods Used to Teach Biostatistics/Epidemiology, Computer Skills, and Critical Review of Literature Subject/Method of Teaching

No of Programs

Biostatistics/epidemiology Consultants Graduate level course Research course through: Department of pediatrics PEM faculty Computer skills Individual help from faculty Formal course Critical review of literature Journal club Formal course

41/44 (93%) 28/41 (68%) 26/41 (63%) 26/41 10/41 29/44 24/29 13/29 44/44 43/44 14/44

(63%) (24%) (65%) (83%) (45%) (100%) (98%) (34%)

elective directors in 36 of 44 programs (82%). Fellows provided feedback on the quality of electives in 43 of 44 (98%) programs. Teaching skills training. Fellows spent an average of 4.7 hours per quarter (range, 1.5 to 7.5 hours) teaching small groups. On average, fellows spent 2 hours per quarter teaching large groups (range, 0 to 7.5 hours). All programs provided feedback from direct observation to help fellows improve their teaching. In addition, half the programs used a formal lecture/discussion for this purpose. Fellows taught Pediatric Advanced Life Support (PALS) courses in 43 of 44 programs (98%); the Advanced Pediatric Life Support (APLS) course was taught by fellows in one program. Research training. Thirty-eight of the 42 2-year-track programs (91%) expected research projects. Twenty-nine of 44 programs (66%) required a prospective and/or a retrospective study. Fourteen of 44 programs (32%) required neither. Fellows were doing basic science research in 6 of 44 programs (14%). The first- and second-year fellows in the 2-year-track programs had a mean of 1.5 _+ 1 and 2.5 _+ 1.5 months dedicated to research,

Abstracts

35t

respectively. The first- and second-year fellows in 3-year-track programs had a mean of 2.5 + 1.5 and 3 -+ 2 months dedicated to research, while third-year fellows had 5 + 1.5 months. On average, fellows spent 7.6 hours per week (range, 0 to 15 hours) in the ED during dedicated research months. The methods used to teach fellows basic principles of biostatistics and epidemiology, computer skills, and critical review of literature are shown in Table 3. The mean duration of a research course was 31 hours (range, 5 to 60); this duration exceeded 60 hours in six programs. Fellows were required to complete a Masters in Public Health (MPH) degree in 3 of 6 (50%) of 3-year-track programs. Research grants were funded in 15 of 21 programs (71%) that had applied for funding. Other research accomplishments of PEM senior fellows and graduates over the last 3 years are shown in Figure 2. Administrative skills training. The number of programs that provided training in administrative skills and the methods used by these programs are noted in Table 4. Fellows did an elective in administrative issues in 3 of 44 programs (7%). In addition, 18 of 44 programs (42%) expected fellows to complete an administrative project. The variations observed by our survey in the number of hours spent in the ED per week and in the percentage of shifts worked by fellows as the most senior physician may be due to different economic resources of programs. In addition, these variations may also reflect a difference of opinion among program directors on the optimal amount of clinical experience with and without supervision.2 Opportunities for research and teaching were regarded as much less important reasons for pursuing a PEM fellowship training than the opportunities for clinical experience by prospective PEM fellows. 3 The vast majority of programs provided some form of training to acquaint fellows with research and teaching skills. It is worth noting that 74% and 46% of the PEM fellowship graduates indicated the need for further training in research and teaching, respectively. 4 This may reflect a group of individuals with primary interest in clinical work, lack of existence of structured teaching curricula, and a potential failure of programs to address

Presentations

34% n=15

32*/. n=14

30

3O

23% n=lO

25

~% n-t0

I

20 1

1(1% 14%

n=7

n=7

14%

n=6

• FIGURE 2. Research accomplishments of PEM fellows and graduates over the previous 3 years.

[ ] 51-75%

27%

27%

n=12

~3~t 26% n-li

None

[ ] 1-25% I ~ 26-50%

Papers

n-7

34%

Case Reports

[ ] 76-100%

n=12

n=12 2618%

n=8

r1~8 12"/. n~6 n=4

n=l

2--1

102

AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 17, Number 1 • January 1999

TABLE4. Methods Used to Accomplish Teaching of Administrative Skills No of Programs (%)

Formal Course

Lecture Discussion

Directed Reading

Quality assurance

41/44 (93%)

1/41 (2%)

17/41 (41%)

12/41 (29%)

Medicolegal issues

31/44 (70%)

1/31 (3%)

28/31 (90%)

14/31 (45%)

Budgeting and finance

29/44 (63%)

1/29 (3%)

19/20 (95%)

6/29 (21%)

Management and leadership skills

29/44 (65%)

1/29 (3%)

20/29 (69%)

12/29 (41%)

Hospital/departmental organizational structure

25/44 (57%)

0

19/25 (76%)

6/25 (24%)

Administrative Skill

training needs of the individual fellows. Although a number of programs provided administrative training, and PEM faculty may spend an average of 7% to 25% of their time carrying out administrative responsibilities, 80% of the PEM fellowship graduates expressed the need for further training in administrative skills.4,5 A large number of fellowship graduates reported a high level of discomfort with the performance of several life-saving procedures in a recent survey.4 Results of our survey indicated varied methods used for technical skills training, poor record-keeping of the procedures performed by fellows, and failure of the programs to require fellows to accomplish a specified number of procedures, such as intubations and deliveries, may be responsible for this. In addition, a low number of patients requiring advanced level of care seen in pediatric EDs, 6 lack of consistent development of goals and objectives for electives, dilution of the clinical experience because of a large number of providers who need practice in the performance of technical skills] and inadequate ongoing education in infrequently performed technical skills may also play a role. The difficulties encountered in the training, evaluation, and retention of technical skills are well recognized in other specialties as well. 8,13 Development of uniform goals and objectives for electives, use of modern technology, establishment of user-friendly programs for the practice of infrequently performed procedures, and development of innovative structured technical skills assessment methods are some of these strategies that have been proposed to counter these problems.8-13 KHAJISTAQAZI, MD, MS Department of Emergency Medicine Division of Emergency and Trauma Services Children's Hospital and Medical Center Akron, OH EMORYPETRACK,MD, MPH Department of Pediatrics Rainbow Babies and Children's Hospital Case Western Reserve University Cleveland, OH

References 1. Curriculum Subcommittee, Section on Emergency Medicine, American Academy of Pediatrics: Pediatric Emergency Medicine (PEM) Fellowship Curriculum Statement. Pediatr Emerg Care 1993; 9:60-66

Other Departmental quality assurance meeting: 37/41 (90%) Staff meeting: 1/41 (2%) Staff meetings: 4/31 (13%) Helping faculty in preparing for court: 2/31 (7%) Help from individual faculty members: 5/29 (17%) Observation of faculty One-on-one discussion Staff meetings Helping faculty with related issues Completion of related projects: 1/29 (3%) Staff meetings: 1/25 (4%) Committee meetings

2. Wiley JF, Hagenbarth MA: Pediatric emergency medicine fellow clinical work requirements. Pediatr Emerg Care 1995; 1i :38i -388 3. Simon HK, Linakis JG: Pediatric emergency medicine fellowship survey: 1991-1992. Pediatr Emerg Care 1992;8:331-333 4. Simon HK, Steele DW, Lewander W J, et al: Are pediatric emergency medicine training programs meeting their goals and objectives? A self-assessment of individuals completing fellowship training in 1993. Pediatr Emerg Care 1994;10:208-212 5. Nozicka CA, Singh J: Training, attitudes, and income profiles of pediatric emergency physicians: The results of a 1993 survey of the American Academy of Pediatrics Section on Emergency Medicine. Pediatr Emerg Care 1995;11:20-26 6. Losek JD, Walsh-Kelly C, Glaeser PW: Pediatric emergency departments. Pediatr Emerg Care 1986;2:215-217 7. Anonymous: Minutes of the Pediatric Emergency Medicine Fellowship Directors Meeting. Pediatr Emerg Care 1991 ;7:325-327 8. MC Arthur CL, Gorchynski J, Rooke C, et al: Objectives to direct the training of emergency medicine residents on off-service rotations in cardiology, part 2. J Emerg Med 1994;12:693-701 9. Hekelman FP, Phillips JA, Bierer LA: An interactive videodisk training program in basic cardiac life support: Implications for staff development. J Contin Educ Nurs 21:245-247 10. Bradbury-Goals K, Carson L: Nursing skills fair: Gaining knowledge with fun and games. J Contin Educ Nurs 1994;25:32-34 11. Connolly HV, Fetcho S, Hageman JR: Education of personnel involved in the transport program. Crit Care Clin 1992;8:481-490 12. Winckel CP, Reznick RK, Cohen R, et al: Reliability and Construct Validity of a Structured Technical Skills Assessment form. Am J Surg 1994;167:423-427 13. Cass OW: Objective Evaluation of Competence: Technical Skills in Gastrointestinal Endoscopy. Endoscopy 1995;27:86-89

RUPTURED RETROPERITONEALANEURYSM IN A PATIENT TAKING PHENTERMINE HYDROCHLORIDE To the Editor:--Sympathomimefic agents are commonly used in weight reduction programs. Contraindications to their use include hypertension, advanced atherosclerosis, symptomatic cardiovascular disease, and hyperthyroidism. This report describes the spontaneous rupture of a retroperitoneal aneurysm in a woman taking phentermine for appetite suppression. A 70-year-old woman was transported to the emergency department (ED) after syncope related to hypotension. She had experienced progressive midabdominal pain for 5 days, associated with diarrhea, but without signs of gastrointestinal bleeding. Two days