- Email: [email protected]
Positive Impact of Transition From Noon Conference to Academic Half Day in a Pediatric Residency Program
Accepted Manuscript The Positive Impact of the Transition from Noon Conference to Academic Half Day in a Pediatric Residency Program Laura Zastoupil, MD, Amanda McIntosh, MD, Jenna Sopfe, MD, Jason Burrows, MD, Jessica Kraynik, MD, Lindsey Lane, BM, BCh, Janice Hanson, PhD, EdS, L Barry Seltz, MD PII:
S1876-2859(17)30011-6
DOI:
10.1016/j.acap.2017.01.009
Reference:
ACAP 974
To appear in:
Academic Pediatrics
Received Date: 17 July 2016 Revised Date:
2 January 2017
Accepted Date: 15 January 2017
Please cite this article as: Zastoupil L, McIntosh A, Sopfe J, Burrows J, Kraynik J, Lane L, Hanson J, Seltz LB, The Positive Impact of the Transition from Noon Conference to Academic Half Day in a Pediatric Residency Program, Academic Pediatrics (2017), doi: 10.1016/j.acap.2017.01.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Corresponding Author: Laura Zastoupil, MD Department of Pediatrics Children’s Hospital Colorado 13123 E 16th Avenue B302 Aurora, CO 80045-7106 Phone: 303-818-3467 Email: [email protected] Fax: 720-777-7873
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Title: The Positive Impact of the Transition from Noon Conference to Academic Half Day in a Pediatric Residency Program
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Author names and affiliations: Laura Zastoupil MD1, Amanda McIntosh MD1, Jenna Sopfe MD1, Jason Burrows MD1, Jessica Kraynik MD1, Lindsey Lane BM, BCh1, Janice Hanson PhD, EdS1, L Barry Seltz MD1 1 Children’s Hospital Colorado and University of Colorado School of Medicine Department of Pediatrics 13123 E 16th Avenue Aurora, CO 80045-7106 United States
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Email addresses of authors: [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Keywords: Didactic, Residency, Medical Education
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Running title: Transition to Academic Half Day in a Residency Program Word counts Abstract – 250 Main – 3500
Research support: Principal Investigators: Laura Zastoupil and Amanda McIntosh Funding for this study was provided by the Department of Pediatrics Medical Education office. The funding source did not have any role in study design, collection, analysis, interpretation of data, the writing of the manuscript, or the decision to submit the manuscript for publication. Conflicts of interest and corporate sponsors: none
ACCEPTED MANUSCRIPT 1 Objective: To evaluate the impact of transitioning from Noon Conference (NC) to Academic Half Day (AHD) on conference attendance, interruptions, and perceived
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protected educational time and to describe pediatric resident experiences with AHD. Methods: In this mixed-methods study, data pre and post AHD-implementation were
collected. Quantitative data were analyzed with a two-variable t-test or chi-square test.
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Five focus groups and five individual interviews of pediatric residents were conducted. Data were analyzed using constant comparative methods, and collected until reaching
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saturation. In accordance with grounded theory methodology, we developed codes using an iterative approach and identified major themes.
Results: Following AHD implementation, resident attendance increased from 55% (of residents expected at NC) to 94% (of residents scheduled for AHD) (P<0.001);
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interruptions decreased from 0.25/resident/hr to 0.01/resident/hr (P<0.001). Positive responses regarding perceived protected educational time improved from 50% to 95% (2015 class) and from 19% to 50% (2016 class) (P < 0.001). Thirty-two residents
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participated in focus groups/interviews. Analysis yielded 5 themes: Aids and Barriers to AHD Attendance; Teaching; Curricular Content; Learning and Engagement; and Resident
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Well-being. Residents felt aided attending AHD when clinical supervisors supported their educational time. Compared to NC, residents noted better topic selection but fewer covered topics. Residents valued protected educational time without clinical responsibilities and felt small-group discussions at AHD facilitated learning. Although cross-covering was stressful, AHD positively contributed to resident well-being.
ACCEPTED MANUSCRIPT 2 Conclusions: AHD improves resident attendance, interruptions, and perceived learning, and contributes to resident wellness. More work is needed to mitigate the workload of
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cross-covering residents.
ACCEPTED MANUSCRIPT 3 What’s New Transition from daily noon conferences to a monthly half-day block improves
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resident attendance with fewer conference interruptions, and is associated with resident perception of better learning. Although cross covering is stressful, overall this
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learning model positively contributes to resident wellness.
ACCEPTED MANUSCRIPT 4 INTRODUCTION
The Accreditation Council for Graduate Medical Education requires that
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residency programs provide regularly scheduled didactic sessions,1 traditionally
accomplished with daily noon conferences (NC). However, several problems exist with
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NC including poor resident attendance, interruptions from clinical responsibilities,
compressed time with duty hour restrictions, and misalignment with adult learning
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principles.2 Some programs have responded by transitioning from daily NC to an academic half-day (AHD), condensing didactic sessions into one half-day block per week.2-6
Few studies have evaluated the impact of transitioning to AHD. AHD
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conferences at several internal medicine programs have demonstrated improved conference attendance, resident satisfaction, and in-training examination (ITE) scores.2,3 Studies in pediatric programs, however, are even sparser. A mid-size pediatric program
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reported improved resident attendance and satisfaction but no improvement in perceived learning following transition to a block conference.4 No previous studies have
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utilized rigorous qualitative methods to better understand resident experiences with an AHD, and the impact of transitioning to an AHD remains largely unclear. A targeted needs assessment of our residency program’s NC revealed poor
resident attendance, frequent interruptions from clinical duties, and dissatisfaction with lack of protected educational time. In response, in September 2014 we transitioned from NC to AHD. The objectives of our study were to answer two questions: 1) what is
ACCEPTED MANUSCRIPT 5 the impact of the transition to AHD on resident attendance, conference interruptions, and perceived protected educational time? and 2) how did residents experience the
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METHODS
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transition to AHD at our institution?
SETTING
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Our pediatric residency program at the University of Colorado has 86 residents covering clinical services at Children’s Hospital Colorado (CHCO), Denver Health Medical Center (DHMC), and University of Colorado Hospital. Our didactic curriculum takes place at CHCO and historically was a one-hour NC occurring 4 days/week and broadcast
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to DHMC. Residents were not scheduled for NC but were expected to attend unless post-call, on vacation, or on night shifts. Residents remained available for clinical responsibilities during conference.
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In 2014, our program transitioned to AHD, in which resident learning is focused into a 3.5 hour block (Tuesdays, 1:30-5:00 PM, one 15-minute break). Several resident
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AHD schedules were discussed in planning meetings with our medical directors and we ultimately agreed upon the following: each resident is scheduled for one AHD per month; PL1s attend the first Tuesday while a mix of PL2s and PL3s is divided between duplicate sessions on the second and third Tuesdays. Residents attending AHD are free from clinical responsibilities. Inpatient service coverage is provided by: PL3s and family medicine interns covering for PL1s, PL2s cross-covering for one another, and cross-
ACCEPTED MANUSCRIPT 6 covering PL3s or hospitalists covering for PL3s. Residents do not return to work after
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AHD.
CURRICULUM STRUCTURE
AHD is a 3-year curriculum with an annually repeating intern curriculum and two
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PL2/PL3 curricula that alternate every other year such that residents progress through residency without repeating content. Currently no effective system exists to provide
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this curriculum to residents unable to attend. Content is delivered through minilectures, small-group case-based learning, board review questions, and games. Each month focuses on a subspecialty theme with topics selected through collaboration between residency program leadership and subspecialty faculty, and based on the
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American Board of Pediatrics Examination content outline. Unlike NC, preparatory reading material is occasionally provided prior to AHD but is neither mandatory nor enforced. All sessions are delivered under the assumption that residents did not
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prepare. Ongoing NCs include resident-led conferences, morbidity and mortality
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conferences, and a summer Emergency Series. Residents still receive lunch daily.
STUDY DESIGN
We performed a mixed-methods study with 1) quantitative data collected pre
and post AHD implementation and 2) qualitative methodology using focus groups and individual interviews of pediatric residents. We included qualitative methodology, as qualitative research is well-suited to answer questions about changes in complex
ACCEPTED MANUSCRIPT 7 learning environments. Multiple methods of data collection were done to establish trustworthiness of findings through triangulation.7 Study participants provided written
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consent for the qualitative portion and our institution’s review board approved the study protocol.
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PURPOSEFUL SAMPLING STRATEGY
Pediatric residents were recruited by e-mail to participate in focus groups
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(October 2014-May 2015) or individual interviews (June 2015), during which time the AHD format did not change. Focus groups were conducted following AHD sessions. Each resident could participate in one focus group or interview and those who had experienced both NC and AHD were asked to compare them. Resident demographics
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were collected including gender, training level, and number of AHDs attended. We continued sampling until qualitative analysis indicated that themes in the residents’ comments were repeating, no new themes emerged, and we had a robust
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understanding of all themes.
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DATA COLLECTION
Study investigators prospectively observed 14 NCs (February-April 2014) and 10
AHDs (October 2014-April 2015), the latter requiring a longer observation period due to its less frequent occurrence. We collected data on resident attendance (% attendance for residents expected [NC] or scheduled [AHD] to attend, and % attendance for all residents at AHD), number of interruptions, and conference length of stay (LOS) (% of
ACCEPTED MANUSCRIPT 8 conference duration residents were present). Investigators reviewed resident schedules to determine number of residents expected to attend NC in person. Residents rotating
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at DHMC (broadcasted NC) were excluded from NC attendance data. We collected pre (2013-2014 academic year) and post (2014-2015 academic year) AHD-implementation
ACGME survey responses (% program compliance, interpreted by ACGME, with having
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an “Appropriate balance between education and service”) and program survey
responses (% strongly agree/agree with “I have protected time to attend didactic
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sessions” and “My clinical workload is appropriate when covering for others attending AHD.”)
Two investigators conducted five focus groups and five individual interviews. Focus groups lasted 30-45 minutes and included 4-6 residents; each interview lasted 15-
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20 minutes. Focus group participants received a light meal and interviewees received $15.00 gift certificates as tokens of appreciation. We used a semi-structured interview guide (Table 1) that focused on resident learning, engagement, and wellness as
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potential outcomes of didactic teaching. In accordance with rigorous qualitative methods,8 we added questions to pursue insights that emerged about residents’
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perspectives as the study proceeded. Interviews were audiotaped, transcribed verbatim, and de-identified.
DATA ANALYSIS Descriptive statistics were used to compare resident attendance, number of interruptions, conference LOS, and survey responses pre/post-AHD implementation.
ACCEPTED MANUSCRIPT 9 Data were analyzed with a standard two-variable t-test or chi-square test. A P-value < 0.05 was considered statistically significant. Qualitative data analysis was conducted simultaneously with data collection and
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in accordance with grounded theory methodology.8,9 Five investigators immersed
themselves in and analyzed the data using the constant comparative method.8,9 All
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investigators individually reviewed transcripts and developed lists of codes. Codes were built using an iterative approach; initial codes were modified and additional ones added
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to best reflect data content. Investigators compared coding as a group and resolved discrepancies by consensus. Using HyperRESEARCH 3.0 to organize the data, themes were identified; investigators returned to the data to verify relationships between themes and created a theory that arose from analysis of the data. Interview guide
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modifications were made systematically in response to emerging codes and themes, enabling thorough exploration of themes and ensuring a rigorous basis for a decision about reaching saturation.7,8 After achieving theoretical saturation, sampling was
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stopped. Trustworthiness of findings was assessed through sequential exploration of emerging hypotheses with subsequent study participants, reflexive team analysis in
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which investigators discussed and checked the data against the literature and their independent experiences,10 and member checking, in which themes and their interpretations were discussed with study participants.7
RESULTS
ACCEPTED MANUSCRIPT 10 Resident Attendance, Conference Interruptions, and Perceived Protected Educational Time
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Not all residents could be scheduled for AHD due to vacations, night shifts, postcall days, and an AHD schedule in which at least one resident remained at each clinical site. Conference attendance increased from 55% (of residents expected in-person for
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NC) to 94% (of residents scheduled for AHD) (P<0.001). AHD attendance for all
(including unscheduled) residents was 74%. LOS increased from 84% to 98% of the
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conference duration (P<0.001). Interruptions from pages and phone calls decreased from 0.25/resident/hr to 0.01/resident/hr (P<0.001).
Following AHD implementation, resident perceptions of having protected educational time improved from 50% to 95% as the class of 2015 progressed from PL2
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to PL3 year (P < 0.001). Likewise, perceptions improved from 19% to 50% for the class of 2016 between the PL1 and PL2 year (P < 0.001). While analysis by individual training level revealed improved perception of protected educational time for PL1s (NC 19%,
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AHD 81%, P<0.001) and PL3s (NC 30%, AHD 95% P<0.001), it was unchanged for PL2s (NC 50%, AHD 50%).
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Survey responses indicated that 86% of PL3s and only 37% of PL2s felt their
clinical workload was appropriate when covering for residents attending AHD. ACGME program compliance with achieving an appropriate balance for education remained similar pre/post AHD implementation (71% vs. 76%, P=0.21).
Residents’ Experiences with AHD: qualitative study
ACCEPTED MANUSCRIPT 11 Thirty-two pediatric residents (Table 2) from all training levels participated in focus groups or individual interviews. PL2s and PL3s often compared AHD to their own
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previous experiences with NC. Data analysis yielded 5 themes and a grounded theory. Themes with representative quotations are presented in the text and in Table 3.
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AIDS AND BARRIERS TO AHD ATTENDANCE
Residents felt aided in attending AHD when their clinical supervisors supported
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their educational time. Residents appreciated when hospitalists covered for senior residents. However, because residents often cross-covered, the covering resident often felt that the workload was difficult. Additionally, residents noted impeded attendance due to this cross-coverage model: “On Heme-Onc and Pulm, there are 3 of us. Someone
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is post-call. One person goes to AHD. So that leaves one person there. That one person is post-call the next week, so there is just no structure for that person to ever be able to
AHD.
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TEACHING
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go.” It was also challenging for residents to complete their work in the morning prior to
Residents valued the varied teaching methods incorporated into AHD. Residents
found the shorter lectures, given as PowerPoint presentations or “chalk talks,” meaningful as they provided focused overviews with important background information. Additionally, with limited teaching time at AHD, residents felt that teachers put more effort into selecting topics and emphasizing “take home pearls” than
ACCEPTED MANUSCRIPT 12 was done with NC. One resident commented: “It puts the presenters under more pressure to come up with a useful topic rather than just filling an hour.” Residents also
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valued interacting with different faculty and fellows. One resident stated: “Attendings really interjected… this is how I think about this. Or this is how I approach this. That is an invaluable resource in these small group settings.” Although the perceived quality of
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teaching varied, residents appreciated the teachers’ enthusiasm.
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CURRICULAR CONTENT
Residents appreciated having separate intern and senior curricula. Residents liked immersing themselves into one specialty per AHD, which allowed them to focus and process that information, and valued content with clinical relevance. One resident
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stated: “The thing I find lacking from noon conference is there is often not a direct application or a pearl. Academic Half Days are very focused … where I walk away with having learned something tangible.” Residents sometimes felt the content was
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irrelevant and desired input into topic selection. Occasionally the volume of information felt rushed or was too much to retain. Residents were also concerned that
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fewer topics were covered compared to NC, potentially leading to knowledge gaps. One resident commented: “You get one day a month. Does that make up for 30 days? I would love to see more.” Many residents desired better reinforcement of learning points and reference materials. Residents acknowledged preparatory pre-reading as potentially beneficial but impractical.
ACCEPTED MANUSCRIPT 13 LEARNING AND ENGAGEMENT Residents appreciated protected learning time free of distractions from clinical
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responsibilities. Senior residents described their previous NC experiences as including late arrivals, frequent interruptions with pages and phone calls, and preoccupation with patient care tasks. One resident described: “Even when I was at noon conference for the
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whole time, like I was not paying attention because it was more just my lunch hour, or a break, a time to decompress.”
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With AHD, residents valued shorter lectures followed by facilitated case applications, allowing information to be explained in greater depth. Small group activities encouraged resident engagement and participation. One resident commented: “I was way more reluctant to participate in Noon Conference format in
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front of everyone than I am in front of a small group.” They felt they learned and retained content better in these interactive formats when they were challenged to synthesize and apply information.
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Sometimes AHD felt long, which negatively impacted the level of engagement although built-in breaks helped. Residents also worried that if they missed an AHD, they
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missed an entire month of learning. One resident stated: “Especially when it is only one subject a month and if you are gone that month, you miss that subject.”
RESIDENT WELL-BEING Residents described ways AHD contributed to their well-being by enhancing socialization, class bonding, and opportunities to learn with their peers. They enjoyed
ACCEPTED MANUSCRIPT 14 free lunch and socializing on days without conference, which rejuvenated residents and provided opportunities to share both good and stressful stories. Residents on busy
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inpatient services found AHD therapeutic and refreshing. One resident commented: “Especially when you’re doing like those 12 or 14 day stretches…knowing that OK, I will be able to get home at a reasonable hour on this day.” Conversely, residents often felt
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guilty attending AHD while their colleagues remained behind to cover the clinical
services. Some residents also described feeling stressed at AHD because they were
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missing aspects of patient care.
GROUNDED THEORY
Figure 1 depicts the theory created in the last phase of data analysis. With
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protected educational time, AHD offers learning for residents through interactive teaching and engaging residents in small groups in which residents are comfortable participating. Although stress may result from peer cross-coverage, AHD can support
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resident wellness.
DISCUSSION
Our study found that, compared to daily NC, AHD yielded significantly improved
resident attendance, markedly fewer interruptions, greater perceived learning, and positive contributions to resident wellness. Many of these outcomes were directly attributed to didactic learning without concurrent clinical responsibilities. The specialtyfocused themes provided review of background information and clinically relevant
ACCEPTED MANUSCRIPT 15 pearls with opportunity for synthesis of information. The diversified structure, utilizing games and small-group sessions, led to perception of better content retention, and
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allowed for collaboration and interaction amongst residents, fellows and faculty.
BUILDING ON EXISTING LITERATURE
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The literature describing the impact of AHD is scarce with inconsistent effects reported on learning. Some studies reported AHD was associated with improved ITE
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scores.2,4,11 In contrast, other studies found that a block conference format was not associated with improved or perceived gain of knowledge.3,12 One block conference focused on delivering lectures,12 which may not have promoted active resident participation, and although another block conference incorporated case-based
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interactive learning, resident perception of interaction was not different from NC.3 This might explain the lack of improved learning outcomes, as functional neurobiological changes associated with learning occur best when the learner is actively engaged.13
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Study differences in learner groups, outcome measures, content delivery methods, and challenges in measuring changes in knowledge may also explain these mixed results.
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Existing literature is further limited by the use of survey methodology, which does not comprehensively explore resident perspectives.
RESIDENT LEARNING Our qualitative analysis significantly adds to the literature by providing a deeper understanding of pediatric residents’ perspectives of AHD. Our findings support
ACCEPTED MANUSCRIPT 16 improved resident perception of learning with AHD, in large part by providing protected educational time free from clinical responsibilities, which allowed residents to focus on
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learning. Equally important was how AHD promoted learner engagement through small-group interactive case discussions. Perhaps more important than having a block schedule may be learner engagement; it may be more feasible to provide a protected
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educational environment and engage learners with AHD than a one-hour conference.
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RESIDENT WELL-BEING
AHD provides an opportunity for residents to socialize, learn together, and get home early from busy inpatient service rotations. Residents in our study described how AHD positively contributed to their wellness, which builds on previous survey results
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that reported a block conference improved resident “connection to co-residents.”3 While AHD overall positively contributed to resident wellness, residents also described stress from cross-covering and feelings of guilt from leaving behind cross-covering
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colleagues. These descriptions raise questions at how this learning model might affect resident burnout. Pediatric residents commonly experience burnout,14 and the Clinical
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Learning Environment Review (CLER) Program expects institutions to educate residents about burnout prevention and measure burnout annually.15 It’s suggested that this expectation could expand to include creation of quality initiatives that enhance resident wellness.16 AHD could be one such initiative, and we speculate that AHD might decrease prevalence of resident burnout, particularly if additional patient care support is provided to alleviate the stress and workload of cross-covering.
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ACADEMIC HALF DAY AND DIDACTIC VOLUME
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Residents were frequently worried that they were receiving an inadequate number of topics with AHD compared to NC. With AHD, an individual resident should receive 7.5 hours/month of didactic education (3.5 hours/month of AHD + 4
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hours/month of ongoing NC) compared to 16 hours/month with NC, although the
amount of didactic time actually received under NC was significantly less due to poor
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resident attendance. The combination of much improved attendance and quality of learning should offset this difference. Additionally, although NC LOS appeared high, it may have been inflated by absence at conference of residents with inpatient responsibilities or afternoon clinics. We suspect if these residents attended NC, LOS
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would have been lower and would have shown even greater improvement with AHD. Some programs that have transitioned to AHD provide weekly block sessions for all residents, which is significantly more than our program’s monthly schedule. Ultimately,
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AHD should be viewed as a tool to deliver improved didactic learning, rather than a
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complete replacement for all formal residency education.
PATIENT CARE CHALLENGES WITH ACADEMIC HALF DAY Another resident concern is the inadequate infrastructure on inpatient units to
provide clinical coverage for residents attending AHD. Other programs describe coverage by the hospitalist service, physician assistants, and other residents/fellows.2 In our initial planning, several medical directors expressed concern about AHD schedules
ACCEPTED MANUSCRIPT 18 that removed residents from clinical sites. While our current model of coverage (at least one resident remains to care for patients at each clinical site) was ultimately
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supported, this dependence on resident cross-coverage to allow protected time for peers has contributed to suboptimal overall attendance at AHD and increased workload for cross-covering residents. This is particularly true for our PL2s, who provide primary
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staffing for inpatient subspecialty services with heavy reliance on PL2 cross-coverage for AHD, resulting in more difficulty scheduling AHD for PL2s than other classes. This
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scheduling difficulty for PL2s likely limited improvement in perceived protected educational time between the PL1 and PL2 year (2016 class), while it resulted in greater improvement between the PL2 and PL3 year (2015 class), as the PL3 year has less AHD cross-covering needs. It highlights the need for improved patient care strategies,
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particularly at large institutions dependent on residents for care needs, as increased patient care workload for covering peers has the potential to threaten the long-term sustainability of our AHD. Applying Bolman and Deal’s four frame conceptual model of
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organizational functioning (structural, human resource, political, symbolic),17 which has been used to analyze other educational programs,18 may optimize the chances of long-
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term success of our AHD. We focused on the structural frame - the development of a new approach to delivering resident education - and the human resource frame – the experience of residents. However, understanding the human resource frame from the perspective of faculty, and exploration of the political and symbolic frames to elucidate the impact of AHD on the broader organization should provide data that contributes to development of a shared understanding that optimizes AHD for all involved.
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LIMITATIONS
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Our study involved pediatric residents at a large academic children’s hospital and therefore our findings may not be transferable to other specialty training programs or
types of institutions. NC and AHD observation periods varied in length and time of year,
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subject to differences in extrinsic effectors on study outcomes (e.g. census).
Additionally, we did not account for NC attendance via broadcast at DHMC, and %
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attendance may have differed when including this small group of residents. Our study is limited by short-term follow up after transition to AHD. Some residents attended only a few AHD sessions, and subjects participated in only one focus group/interview. It’s possible resident perspectives on AHD benefits and challenges may have differed with
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longer-term experiences. Finally, we did not objectively assess learning.
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We plan to explore repetition of critical topics to remedy the lack of make-up structure for residents missing AHD. In addition, we plan to evaluate the long-term
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learning outcomes of AHD, and the perspectives of faculty conducting AHD, faculty responsible for patient care, and clinical care leaders at our varying sites.
CONCLUSIONS An Academic Half Day, providing protected educational time with active engagement, improves resident attendance, interruptions, and perceived learning, and
ACCEPTED MANUSCRIPT 20 positively contributes to resident wellness. Although challenges with didactic volume and patient care coverage remain, residency programs could consider developing an
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ACKNOWLEDGEMENTS
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Academic Half Day that mitigates many of the problems with noon conference.
Funding was provided by the University of Colorado, Department of Pediatrics Medical
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Education office. All authors have roles in the Office of Education (OOE) but grant
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funding is an independent function administered by and within the OOE.
ACCEPTED MANUSCRIPT 21 REFERENCES
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1. Accreditation Council for Graduate Medical Education in Pediatrics. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQPIF/320_pediatrics_07012013.pdf. Accessed April 15, 2016 2. Batalden M, Warm E, Logio L. Beyond a Curricular Design of Convenience: Replacing the Noon Conference With an Academic Day in Three Internal Medicine Residency Programs. Acad Med. 2013;88:644-651
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3. Moreno M, Kota R, McIntosh G, Frohna J. PEARLs of Wisdom: Impact of a New Block Conference on Pediatrics Resident Attendance, Satisfaction, and Learning. J Grad Med Educ. 2013;5:323-326 4. Ha D, Faulx M, Isada C, et al. Transitioning From a Noon Conference to an Academic Half-Day Curriculum Model: Effect on Medical Knowledge Acquisition and Learning Satisfaction. J Grad Med Educ 2014;6:93-99
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5. Chalk C. The Academic Half-Day in Canadian Neurology Residency Programs. Can J Neurol Sci 2004;31:511-513 6. Zweifler J, Ringel M, Maudlin R, Blossom H. Extended Educational Sessions at Three Family Medicine Residency Programs. Acad Med 1996;71:1059-1063
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7. Hanson J, Balmer D, Giardino A. Qualitative Research Methods for Medical Educators. Acad Pediatr 2011;11:375-386
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8. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 3rd ed. Los Angeles, Ca: Sage;2008 9. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. New Brunswick, NJ: Aldine Publishing Company;2010 10. Barry C, Britten N, Barber N, et al. Using reflexivity to optimize teamwork in qualitative research. Qual Health Res 1999;9:26-44
ACCEPTED MANUSCRIPT 22 11. Eid A, Hsieh P, Shah P, Wolff R. Cross-sectional longitudinal study of the academic half-day format in a hematology-oncology fellowship training program. BMC Med Educ 2015;15:1-8
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12. Winter R, Picciano A, Birnberg B, et al. Resident Knowledge Acquisition During a Block Conference Series. Fam Med 2007;39:498-503
13. Friedlander M, Andrews L, Armstrong E, et al. What Can Medical Education Learn From the Neurobiology of Learning? Acad Med 2011;86:415-420
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14. Pantaleoni J, Augustine E, Sourkes B, Bachrach L. Burnout in Pediatric Residents Over a 2-Year Period: A Longitudinal Study. Acad Pediatr 2014;14:167-172
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15. Accreditation Council of Graduate Medical Education. CLER pathways to excellence: Expectations for an optimal clinical learning environment to achieve safe and high quality patient care. 2014. https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf. Accessed November 4, 2016.
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16. Jennings ML, Slavin S. Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment. Acad Med 2015;90:1246-1250 17. Bolman LG, Deal TE. Reframing Organizations: Artistry, Choice, and Leadership. San Francisco, Calif: Jossey-Bass; 1991
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18. Swan-Sein A, Mellman L, Balmer D, Richards B. Sustaining an Advisory Dean Program Through Continuous Improvement and Evaluation. Acad Med 2012;87:1-6
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Table 1. Questions for Focus Groups and Individual Interviews 1. What are your general impressions about AHD compared to noon conference? 2. How do you feel the implementation of AHD has impacted resident wellness? 3. How has AHD affected camaraderie with your resident colleagues? 4. Tell me about your level of satisfaction with AHD. 5. How would you describe your level of engagement in AHD compared to noon conference? 6. What obstacles to learning have you found with AHD? 7. Tell me about how well you feel you sustain long-term knowledge with AHD compared to daily noon conference. 8. How do you feel your level of engagement affects your learning?a 9. How do you feel small groups affect your learning?a 10. We’ve heard in previous groups that you feel more willing to participate or that AHD is possibly less intimidating. What do you think?a 11. How do you feel about having a 3-year curriculum?a 12. How do you feel AHD has affected the quality of patient care?a a Question was added to interview guide as part of iterative process based on comments from previous groups
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Table 2. Demographic Data of Focus Group and Individual Interview Participants (N=32) Characteristic n (%) Male 7 (19) Post-Graduate Year 1 11 (31) 2 11 (39) 3 10 (31) Number of AHD Sessions Attended 1 2 (6) 2 6 (17) 3 8 (22) >3 16 (56) Preferred Learning Style Lecture only 0 (0) Small group, case-based 9 (28) Lecture + small group 20 (63) Other 3 (8)
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Quotation “I think the hospitalist team has really bought into AHD and are willing to cover and I'm not sure all of the sub-specialties are there yet.”
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Table 3. Themes with Illustrative Quotations Theme Aids and Barriers to Attending AHD
“The one challenge that I've seen is when you are on nights, you don't get to go.”
Curricular Content
“I was the Senior on the wards covering when the interns were gone. And that was a crazy afternoon. It was hard.” “It is nice to see that the faculty is engaged in developing the curriculum and that they want to be there.”
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Teaching
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“You’re cramming your whole day’s work into the half-day.”
“They did do a really, really nice mix of lecture and then application and then lecture and application.” “I think it is a set up for gaps in knowledge.”
Resident Well-being
“But if you miss that one day, you are missing essentially a month of teaching. “I think it is kind of therapeutic and it is refreshing to just have a chance to step away from the grind and focus on investing in your education for being a better clinician.”
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Learning and Engagement
“They are definitely more practical. They are more memorable. And definitely more applicable.” “The pagers are off. So mentally you have much more attentiveness. And, I've found myself asking quite a few more questions and being more engaged.”
“It is really hard for me to leave my colleague on the ward that is covering the service.”
“I felt like I was abandoning her up there. You just feel bad when you’re leaving somebody with a lot of stuff.”
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Resident WELL-BEING
Productive LEARNING
+
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Resident crosscoverage
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_
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Teaching
Learning Climate Focus on learning Comfort of smaller group setting Peer support
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Active teaching strategies Practical & relevant content
+
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No clinical responsibilities + No need to return to work
Figure 1. Effects of Academic Half Day on Resident Well-Being and Learning
S1876-2859(17)30011-6
DOI:
10.1016/j.acap.2017.01.009
Reference:
ACAP 974
To appear in:
Academic Pediatrics
Received Date: 17 July 2016 Revised Date:
2 January 2017
Accepted Date: 15 January 2017
Please cite this article as: Zastoupil L, McIntosh A, Sopfe J, Burrows J, Kraynik J, Lane L, Hanson J, Seltz LB, The Positive Impact of the Transition from Noon Conference to Academic Half Day in a Pediatric Residency Program, Academic Pediatrics (2017), doi: 10.1016/j.acap.2017.01.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Corresponding Author: Laura Zastoupil, MD Department of Pediatrics Children’s Hospital Colorado 13123 E 16th Avenue B302 Aurora, CO 80045-7106 Phone: 303-818-3467 Email: [email protected] Fax: 720-777-7873
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Title: The Positive Impact of the Transition from Noon Conference to Academic Half Day in a Pediatric Residency Program
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Author names and affiliations: Laura Zastoupil MD1, Amanda McIntosh MD1, Jenna Sopfe MD1, Jason Burrows MD1, Jessica Kraynik MD1, Lindsey Lane BM, BCh1, Janice Hanson PhD, EdS1, L Barry Seltz MD1 1 Children’s Hospital Colorado and University of Colorado School of Medicine Department of Pediatrics 13123 E 16th Avenue Aurora, CO 80045-7106 United States
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Email addresses of authors: [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Keywords: Didactic, Residency, Medical Education
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Running title: Transition to Academic Half Day in a Residency Program Word counts Abstract – 250 Main – 3500
Research support: Principal Investigators: Laura Zastoupil and Amanda McIntosh Funding for this study was provided by the Department of Pediatrics Medical Education office. The funding source did not have any role in study design, collection, analysis, interpretation of data, the writing of the manuscript, or the decision to submit the manuscript for publication. Conflicts of interest and corporate sponsors: none
ACCEPTED MANUSCRIPT 1 Objective: To evaluate the impact of transitioning from Noon Conference (NC) to Academic Half Day (AHD) on conference attendance, interruptions, and perceived
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protected educational time and to describe pediatric resident experiences with AHD. Methods: In this mixed-methods study, data pre and post AHD-implementation were
collected. Quantitative data were analyzed with a two-variable t-test or chi-square test.
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Five focus groups and five individual interviews of pediatric residents were conducted. Data were analyzed using constant comparative methods, and collected until reaching
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saturation. In accordance with grounded theory methodology, we developed codes using an iterative approach and identified major themes.
Results: Following AHD implementation, resident attendance increased from 55% (of residents expected at NC) to 94% (of residents scheduled for AHD) (P<0.001);
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interruptions decreased from 0.25/resident/hr to 0.01/resident/hr (P<0.001). Positive responses regarding perceived protected educational time improved from 50% to 95% (2015 class) and from 19% to 50% (2016 class) (P < 0.001). Thirty-two residents
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participated in focus groups/interviews. Analysis yielded 5 themes: Aids and Barriers to AHD Attendance; Teaching; Curricular Content; Learning and Engagement; and Resident
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Well-being. Residents felt aided attending AHD when clinical supervisors supported their educational time. Compared to NC, residents noted better topic selection but fewer covered topics. Residents valued protected educational time without clinical responsibilities and felt small-group discussions at AHD facilitated learning. Although cross-covering was stressful, AHD positively contributed to resident well-being.
ACCEPTED MANUSCRIPT 2 Conclusions: AHD improves resident attendance, interruptions, and perceived learning, and contributes to resident wellness. More work is needed to mitigate the workload of
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cross-covering residents.
ACCEPTED MANUSCRIPT 3 What’s New Transition from daily noon conferences to a monthly half-day block improves
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resident attendance with fewer conference interruptions, and is associated with resident perception of better learning. Although cross covering is stressful, overall this
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learning model positively contributes to resident wellness.
ACCEPTED MANUSCRIPT 4 INTRODUCTION
The Accreditation Council for Graduate Medical Education requires that
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residency programs provide regularly scheduled didactic sessions,1 traditionally
accomplished with daily noon conferences (NC). However, several problems exist with
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NC including poor resident attendance, interruptions from clinical responsibilities,
compressed time with duty hour restrictions, and misalignment with adult learning
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principles.2 Some programs have responded by transitioning from daily NC to an academic half-day (AHD), condensing didactic sessions into one half-day block per week.2-6
Few studies have evaluated the impact of transitioning to AHD. AHD
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conferences at several internal medicine programs have demonstrated improved conference attendance, resident satisfaction, and in-training examination (ITE) scores.2,3 Studies in pediatric programs, however, are even sparser. A mid-size pediatric program
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reported improved resident attendance and satisfaction but no improvement in perceived learning following transition to a block conference.4 No previous studies have
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utilized rigorous qualitative methods to better understand resident experiences with an AHD, and the impact of transitioning to an AHD remains largely unclear. A targeted needs assessment of our residency program’s NC revealed poor
resident attendance, frequent interruptions from clinical duties, and dissatisfaction with lack of protected educational time. In response, in September 2014 we transitioned from NC to AHD. The objectives of our study were to answer two questions: 1) what is
ACCEPTED MANUSCRIPT 5 the impact of the transition to AHD on resident attendance, conference interruptions, and perceived protected educational time? and 2) how did residents experience the
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METHODS
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transition to AHD at our institution?
SETTING
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Our pediatric residency program at the University of Colorado has 86 residents covering clinical services at Children’s Hospital Colorado (CHCO), Denver Health Medical Center (DHMC), and University of Colorado Hospital. Our didactic curriculum takes place at CHCO and historically was a one-hour NC occurring 4 days/week and broadcast
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to DHMC. Residents were not scheduled for NC but were expected to attend unless post-call, on vacation, or on night shifts. Residents remained available for clinical responsibilities during conference.
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In 2014, our program transitioned to AHD, in which resident learning is focused into a 3.5 hour block (Tuesdays, 1:30-5:00 PM, one 15-minute break). Several resident
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AHD schedules were discussed in planning meetings with our medical directors and we ultimately agreed upon the following: each resident is scheduled for one AHD per month; PL1s attend the first Tuesday while a mix of PL2s and PL3s is divided between duplicate sessions on the second and third Tuesdays. Residents attending AHD are free from clinical responsibilities. Inpatient service coverage is provided by: PL3s and family medicine interns covering for PL1s, PL2s cross-covering for one another, and cross-
ACCEPTED MANUSCRIPT 6 covering PL3s or hospitalists covering for PL3s. Residents do not return to work after
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AHD.
CURRICULUM STRUCTURE
AHD is a 3-year curriculum with an annually repeating intern curriculum and two
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PL2/PL3 curricula that alternate every other year such that residents progress through residency without repeating content. Currently no effective system exists to provide
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this curriculum to residents unable to attend. Content is delivered through minilectures, small-group case-based learning, board review questions, and games. Each month focuses on a subspecialty theme with topics selected through collaboration between residency program leadership and subspecialty faculty, and based on the
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American Board of Pediatrics Examination content outline. Unlike NC, preparatory reading material is occasionally provided prior to AHD but is neither mandatory nor enforced. All sessions are delivered under the assumption that residents did not
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prepare. Ongoing NCs include resident-led conferences, morbidity and mortality
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conferences, and a summer Emergency Series. Residents still receive lunch daily.
STUDY DESIGN
We performed a mixed-methods study with 1) quantitative data collected pre
and post AHD implementation and 2) qualitative methodology using focus groups and individual interviews of pediatric residents. We included qualitative methodology, as qualitative research is well-suited to answer questions about changes in complex
ACCEPTED MANUSCRIPT 7 learning environments. Multiple methods of data collection were done to establish trustworthiness of findings through triangulation.7 Study participants provided written
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consent for the qualitative portion and our institution’s review board approved the study protocol.
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PURPOSEFUL SAMPLING STRATEGY
Pediatric residents were recruited by e-mail to participate in focus groups
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(October 2014-May 2015) or individual interviews (June 2015), during which time the AHD format did not change. Focus groups were conducted following AHD sessions. Each resident could participate in one focus group or interview and those who had experienced both NC and AHD were asked to compare them. Resident demographics
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were collected including gender, training level, and number of AHDs attended. We continued sampling until qualitative analysis indicated that themes in the residents’ comments were repeating, no new themes emerged, and we had a robust
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understanding of all themes.
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DATA COLLECTION
Study investigators prospectively observed 14 NCs (February-April 2014) and 10
AHDs (October 2014-April 2015), the latter requiring a longer observation period due to its less frequent occurrence. We collected data on resident attendance (% attendance for residents expected [NC] or scheduled [AHD] to attend, and % attendance for all residents at AHD), number of interruptions, and conference length of stay (LOS) (% of
ACCEPTED MANUSCRIPT 8 conference duration residents were present). Investigators reviewed resident schedules to determine number of residents expected to attend NC in person. Residents rotating
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at DHMC (broadcasted NC) were excluded from NC attendance data. We collected pre (2013-2014 academic year) and post (2014-2015 academic year) AHD-implementation
ACGME survey responses (% program compliance, interpreted by ACGME, with having
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an “Appropriate balance between education and service”) and program survey
responses (% strongly agree/agree with “I have protected time to attend didactic
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sessions” and “My clinical workload is appropriate when covering for others attending AHD.”)
Two investigators conducted five focus groups and five individual interviews. Focus groups lasted 30-45 minutes and included 4-6 residents; each interview lasted 15-
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20 minutes. Focus group participants received a light meal and interviewees received $15.00 gift certificates as tokens of appreciation. We used a semi-structured interview guide (Table 1) that focused on resident learning, engagement, and wellness as
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potential outcomes of didactic teaching. In accordance with rigorous qualitative methods,8 we added questions to pursue insights that emerged about residents’
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perspectives as the study proceeded. Interviews were audiotaped, transcribed verbatim, and de-identified.
DATA ANALYSIS Descriptive statistics were used to compare resident attendance, number of interruptions, conference LOS, and survey responses pre/post-AHD implementation.
ACCEPTED MANUSCRIPT 9 Data were analyzed with a standard two-variable t-test or chi-square test. A P-value < 0.05 was considered statistically significant. Qualitative data analysis was conducted simultaneously with data collection and
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in accordance with grounded theory methodology.8,9 Five investigators immersed
themselves in and analyzed the data using the constant comparative method.8,9 All
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investigators individually reviewed transcripts and developed lists of codes. Codes were built using an iterative approach; initial codes were modified and additional ones added
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to best reflect data content. Investigators compared coding as a group and resolved discrepancies by consensus. Using HyperRESEARCH 3.0 to organize the data, themes were identified; investigators returned to the data to verify relationships between themes and created a theory that arose from analysis of the data. Interview guide
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modifications were made systematically in response to emerging codes and themes, enabling thorough exploration of themes and ensuring a rigorous basis for a decision about reaching saturation.7,8 After achieving theoretical saturation, sampling was
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stopped. Trustworthiness of findings was assessed through sequential exploration of emerging hypotheses with subsequent study participants, reflexive team analysis in
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which investigators discussed and checked the data against the literature and their independent experiences,10 and member checking, in which themes and their interpretations were discussed with study participants.7
RESULTS
ACCEPTED MANUSCRIPT 10 Resident Attendance, Conference Interruptions, and Perceived Protected Educational Time
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Not all residents could be scheduled for AHD due to vacations, night shifts, postcall days, and an AHD schedule in which at least one resident remained at each clinical site. Conference attendance increased from 55% (of residents expected in-person for
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NC) to 94% (of residents scheduled for AHD) (P<0.001). AHD attendance for all
(including unscheduled) residents was 74%. LOS increased from 84% to 98% of the
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conference duration (P<0.001). Interruptions from pages and phone calls decreased from 0.25/resident/hr to 0.01/resident/hr (P<0.001).
Following AHD implementation, resident perceptions of having protected educational time improved from 50% to 95% as the class of 2015 progressed from PL2
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to PL3 year (P < 0.001). Likewise, perceptions improved from 19% to 50% for the class of 2016 between the PL1 and PL2 year (P < 0.001). While analysis by individual training level revealed improved perception of protected educational time for PL1s (NC 19%,
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AHD 81%, P<0.001) and PL3s (NC 30%, AHD 95% P<0.001), it was unchanged for PL2s (NC 50%, AHD 50%).
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Survey responses indicated that 86% of PL3s and only 37% of PL2s felt their
clinical workload was appropriate when covering for residents attending AHD. ACGME program compliance with achieving an appropriate balance for education remained similar pre/post AHD implementation (71% vs. 76%, P=0.21).
Residents’ Experiences with AHD: qualitative study
ACCEPTED MANUSCRIPT 11 Thirty-two pediatric residents (Table 2) from all training levels participated in focus groups or individual interviews. PL2s and PL3s often compared AHD to their own
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previous experiences with NC. Data analysis yielded 5 themes and a grounded theory. Themes with representative quotations are presented in the text and in Table 3.
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AIDS AND BARRIERS TO AHD ATTENDANCE
Residents felt aided in attending AHD when their clinical supervisors supported
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their educational time. Residents appreciated when hospitalists covered for senior residents. However, because residents often cross-covered, the covering resident often felt that the workload was difficult. Additionally, residents noted impeded attendance due to this cross-coverage model: “On Heme-Onc and Pulm, there are 3 of us. Someone
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is post-call. One person goes to AHD. So that leaves one person there. That one person is post-call the next week, so there is just no structure for that person to ever be able to
AHD.
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TEACHING
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go.” It was also challenging for residents to complete their work in the morning prior to
Residents valued the varied teaching methods incorporated into AHD. Residents
found the shorter lectures, given as PowerPoint presentations or “chalk talks,” meaningful as they provided focused overviews with important background information. Additionally, with limited teaching time at AHD, residents felt that teachers put more effort into selecting topics and emphasizing “take home pearls” than
ACCEPTED MANUSCRIPT 12 was done with NC. One resident commented: “It puts the presenters under more pressure to come up with a useful topic rather than just filling an hour.” Residents also
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valued interacting with different faculty and fellows. One resident stated: “Attendings really interjected… this is how I think about this. Or this is how I approach this. That is an invaluable resource in these small group settings.” Although the perceived quality of
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teaching varied, residents appreciated the teachers’ enthusiasm.
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CURRICULAR CONTENT
Residents appreciated having separate intern and senior curricula. Residents liked immersing themselves into one specialty per AHD, which allowed them to focus and process that information, and valued content with clinical relevance. One resident
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stated: “The thing I find lacking from noon conference is there is often not a direct application or a pearl. Academic Half Days are very focused … where I walk away with having learned something tangible.” Residents sometimes felt the content was
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irrelevant and desired input into topic selection. Occasionally the volume of information felt rushed or was too much to retain. Residents were also concerned that
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fewer topics were covered compared to NC, potentially leading to knowledge gaps. One resident commented: “You get one day a month. Does that make up for 30 days? I would love to see more.” Many residents desired better reinforcement of learning points and reference materials. Residents acknowledged preparatory pre-reading as potentially beneficial but impractical.
ACCEPTED MANUSCRIPT 13 LEARNING AND ENGAGEMENT Residents appreciated protected learning time free of distractions from clinical
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responsibilities. Senior residents described their previous NC experiences as including late arrivals, frequent interruptions with pages and phone calls, and preoccupation with patient care tasks. One resident described: “Even when I was at noon conference for the
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whole time, like I was not paying attention because it was more just my lunch hour, or a break, a time to decompress.”
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With AHD, residents valued shorter lectures followed by facilitated case applications, allowing information to be explained in greater depth. Small group activities encouraged resident engagement and participation. One resident commented: “I was way more reluctant to participate in Noon Conference format in
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front of everyone than I am in front of a small group.” They felt they learned and retained content better in these interactive formats when they were challenged to synthesize and apply information.
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Sometimes AHD felt long, which negatively impacted the level of engagement although built-in breaks helped. Residents also worried that if they missed an AHD, they
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missed an entire month of learning. One resident stated: “Especially when it is only one subject a month and if you are gone that month, you miss that subject.”
RESIDENT WELL-BEING Residents described ways AHD contributed to their well-being by enhancing socialization, class bonding, and opportunities to learn with their peers. They enjoyed
ACCEPTED MANUSCRIPT 14 free lunch and socializing on days without conference, which rejuvenated residents and provided opportunities to share both good and stressful stories. Residents on busy
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inpatient services found AHD therapeutic and refreshing. One resident commented: “Especially when you’re doing like those 12 or 14 day stretches…knowing that OK, I will be able to get home at a reasonable hour on this day.” Conversely, residents often felt
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guilty attending AHD while their colleagues remained behind to cover the clinical
services. Some residents also described feeling stressed at AHD because they were
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missing aspects of patient care.
GROUNDED THEORY
Figure 1 depicts the theory created in the last phase of data analysis. With
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protected educational time, AHD offers learning for residents through interactive teaching and engaging residents in small groups in which residents are comfortable participating. Although stress may result from peer cross-coverage, AHD can support
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resident wellness.
DISCUSSION
Our study found that, compared to daily NC, AHD yielded significantly improved
resident attendance, markedly fewer interruptions, greater perceived learning, and positive contributions to resident wellness. Many of these outcomes were directly attributed to didactic learning without concurrent clinical responsibilities. The specialtyfocused themes provided review of background information and clinically relevant
ACCEPTED MANUSCRIPT 15 pearls with opportunity for synthesis of information. The diversified structure, utilizing games and small-group sessions, led to perception of better content retention, and
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allowed for collaboration and interaction amongst residents, fellows and faculty.
BUILDING ON EXISTING LITERATURE
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The literature describing the impact of AHD is scarce with inconsistent effects reported on learning. Some studies reported AHD was associated with improved ITE
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scores.2,4,11 In contrast, other studies found that a block conference format was not associated with improved or perceived gain of knowledge.3,12 One block conference focused on delivering lectures,12 which may not have promoted active resident participation, and although another block conference incorporated case-based
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interactive learning, resident perception of interaction was not different from NC.3 This might explain the lack of improved learning outcomes, as functional neurobiological changes associated with learning occur best when the learner is actively engaged.13
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Study differences in learner groups, outcome measures, content delivery methods, and challenges in measuring changes in knowledge may also explain these mixed results.
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Existing literature is further limited by the use of survey methodology, which does not comprehensively explore resident perspectives.
RESIDENT LEARNING Our qualitative analysis significantly adds to the literature by providing a deeper understanding of pediatric residents’ perspectives of AHD. Our findings support
ACCEPTED MANUSCRIPT 16 improved resident perception of learning with AHD, in large part by providing protected educational time free from clinical responsibilities, which allowed residents to focus on
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learning. Equally important was how AHD promoted learner engagement through small-group interactive case discussions. Perhaps more important than having a block schedule may be learner engagement; it may be more feasible to provide a protected
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educational environment and engage learners with AHD than a one-hour conference.
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RESIDENT WELL-BEING
AHD provides an opportunity for residents to socialize, learn together, and get home early from busy inpatient service rotations. Residents in our study described how AHD positively contributed to their wellness, which builds on previous survey results
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that reported a block conference improved resident “connection to co-residents.”3 While AHD overall positively contributed to resident wellness, residents also described stress from cross-covering and feelings of guilt from leaving behind cross-covering
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colleagues. These descriptions raise questions at how this learning model might affect resident burnout. Pediatric residents commonly experience burnout,14 and the Clinical
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Learning Environment Review (CLER) Program expects institutions to educate residents about burnout prevention and measure burnout annually.15 It’s suggested that this expectation could expand to include creation of quality initiatives that enhance resident wellness.16 AHD could be one such initiative, and we speculate that AHD might decrease prevalence of resident burnout, particularly if additional patient care support is provided to alleviate the stress and workload of cross-covering.
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ACADEMIC HALF DAY AND DIDACTIC VOLUME
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Residents were frequently worried that they were receiving an inadequate number of topics with AHD compared to NC. With AHD, an individual resident should receive 7.5 hours/month of didactic education (3.5 hours/month of AHD + 4
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hours/month of ongoing NC) compared to 16 hours/month with NC, although the
amount of didactic time actually received under NC was significantly less due to poor
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resident attendance. The combination of much improved attendance and quality of learning should offset this difference. Additionally, although NC LOS appeared high, it may have been inflated by absence at conference of residents with inpatient responsibilities or afternoon clinics. We suspect if these residents attended NC, LOS
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would have been lower and would have shown even greater improvement with AHD. Some programs that have transitioned to AHD provide weekly block sessions for all residents, which is significantly more than our program’s monthly schedule. Ultimately,
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AHD should be viewed as a tool to deliver improved didactic learning, rather than a
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complete replacement for all formal residency education.
PATIENT CARE CHALLENGES WITH ACADEMIC HALF DAY Another resident concern is the inadequate infrastructure on inpatient units to
provide clinical coverage for residents attending AHD. Other programs describe coverage by the hospitalist service, physician assistants, and other residents/fellows.2 In our initial planning, several medical directors expressed concern about AHD schedules
ACCEPTED MANUSCRIPT 18 that removed residents from clinical sites. While our current model of coverage (at least one resident remains to care for patients at each clinical site) was ultimately
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supported, this dependence on resident cross-coverage to allow protected time for peers has contributed to suboptimal overall attendance at AHD and increased workload for cross-covering residents. This is particularly true for our PL2s, who provide primary
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staffing for inpatient subspecialty services with heavy reliance on PL2 cross-coverage for AHD, resulting in more difficulty scheduling AHD for PL2s than other classes. This
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scheduling difficulty for PL2s likely limited improvement in perceived protected educational time between the PL1 and PL2 year (2016 class), while it resulted in greater improvement between the PL2 and PL3 year (2015 class), as the PL3 year has less AHD cross-covering needs. It highlights the need for improved patient care strategies,
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particularly at large institutions dependent on residents for care needs, as increased patient care workload for covering peers has the potential to threaten the long-term sustainability of our AHD. Applying Bolman and Deal’s four frame conceptual model of
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organizational functioning (structural, human resource, political, symbolic),17 which has been used to analyze other educational programs,18 may optimize the chances of long-
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term success of our AHD. We focused on the structural frame - the development of a new approach to delivering resident education - and the human resource frame – the experience of residents. However, understanding the human resource frame from the perspective of faculty, and exploration of the political and symbolic frames to elucidate the impact of AHD on the broader organization should provide data that contributes to development of a shared understanding that optimizes AHD for all involved.
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LIMITATIONS
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Our study involved pediatric residents at a large academic children’s hospital and therefore our findings may not be transferable to other specialty training programs or
types of institutions. NC and AHD observation periods varied in length and time of year,
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subject to differences in extrinsic effectors on study outcomes (e.g. census).
Additionally, we did not account for NC attendance via broadcast at DHMC, and %
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attendance may have differed when including this small group of residents. Our study is limited by short-term follow up after transition to AHD. Some residents attended only a few AHD sessions, and subjects participated in only one focus group/interview. It’s possible resident perspectives on AHD benefits and challenges may have differed with
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longer-term experiences. Finally, we did not objectively assess learning.
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We plan to explore repetition of critical topics to remedy the lack of make-up structure for residents missing AHD. In addition, we plan to evaluate the long-term
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learning outcomes of AHD, and the perspectives of faculty conducting AHD, faculty responsible for patient care, and clinical care leaders at our varying sites.
CONCLUSIONS An Academic Half Day, providing protected educational time with active engagement, improves resident attendance, interruptions, and perceived learning, and
ACCEPTED MANUSCRIPT 20 positively contributes to resident wellness. Although challenges with didactic volume and patient care coverage remain, residency programs could consider developing an
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ACKNOWLEDGEMENTS
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Academic Half Day that mitigates many of the problems with noon conference.
Funding was provided by the University of Colorado, Department of Pediatrics Medical
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Education office. All authors have roles in the Office of Education (OOE) but grant
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funding is an independent function administered by and within the OOE.
ACCEPTED MANUSCRIPT 21 REFERENCES
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1. Accreditation Council for Graduate Medical Education in Pediatrics. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQPIF/320_pediatrics_07012013.pdf. Accessed April 15, 2016 2. Batalden M, Warm E, Logio L. Beyond a Curricular Design of Convenience: Replacing the Noon Conference With an Academic Day in Three Internal Medicine Residency Programs. Acad Med. 2013;88:644-651
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3. Moreno M, Kota R, McIntosh G, Frohna J. PEARLs of Wisdom: Impact of a New Block Conference on Pediatrics Resident Attendance, Satisfaction, and Learning. J Grad Med Educ. 2013;5:323-326 4. Ha D, Faulx M, Isada C, et al. Transitioning From a Noon Conference to an Academic Half-Day Curriculum Model: Effect on Medical Knowledge Acquisition and Learning Satisfaction. J Grad Med Educ 2014;6:93-99
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5. Chalk C. The Academic Half-Day in Canadian Neurology Residency Programs. Can J Neurol Sci 2004;31:511-513 6. Zweifler J, Ringel M, Maudlin R, Blossom H. Extended Educational Sessions at Three Family Medicine Residency Programs. Acad Med 1996;71:1059-1063
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7. Hanson J, Balmer D, Giardino A. Qualitative Research Methods for Medical Educators. Acad Pediatr 2011;11:375-386
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8. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 3rd ed. Los Angeles, Ca: Sage;2008 9. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. New Brunswick, NJ: Aldine Publishing Company;2010 10. Barry C, Britten N, Barber N, et al. Using reflexivity to optimize teamwork in qualitative research. Qual Health Res 1999;9:26-44
ACCEPTED MANUSCRIPT 22 11. Eid A, Hsieh P, Shah P, Wolff R. Cross-sectional longitudinal study of the academic half-day format in a hematology-oncology fellowship training program. BMC Med Educ 2015;15:1-8
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12. Winter R, Picciano A, Birnberg B, et al. Resident Knowledge Acquisition During a Block Conference Series. Fam Med 2007;39:498-503
13. Friedlander M, Andrews L, Armstrong E, et al. What Can Medical Education Learn From the Neurobiology of Learning? Acad Med 2011;86:415-420
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14. Pantaleoni J, Augustine E, Sourkes B, Bachrach L. Burnout in Pediatric Residents Over a 2-Year Period: A Longitudinal Study. Acad Pediatr 2014;14:167-172
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15. Accreditation Council of Graduate Medical Education. CLER pathways to excellence: Expectations for an optimal clinical learning environment to achieve safe and high quality patient care. 2014. https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf. Accessed November 4, 2016.
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16. Jennings ML, Slavin S. Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment. Acad Med 2015;90:1246-1250 17. Bolman LG, Deal TE. Reframing Organizations: Artistry, Choice, and Leadership. San Francisco, Calif: Jossey-Bass; 1991
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18. Swan-Sein A, Mellman L, Balmer D, Richards B. Sustaining an Advisory Dean Program Through Continuous Improvement and Evaluation. Acad Med 2012;87:1-6
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Table 1. Questions for Focus Groups and Individual Interviews 1. What are your general impressions about AHD compared to noon conference? 2. How do you feel the implementation of AHD has impacted resident wellness? 3. How has AHD affected camaraderie with your resident colleagues? 4. Tell me about your level of satisfaction with AHD. 5. How would you describe your level of engagement in AHD compared to noon conference? 6. What obstacles to learning have you found with AHD? 7. Tell me about how well you feel you sustain long-term knowledge with AHD compared to daily noon conference. 8. How do you feel your level of engagement affects your learning?a 9. How do you feel small groups affect your learning?a 10. We’ve heard in previous groups that you feel more willing to participate or that AHD is possibly less intimidating. What do you think?a 11. How do you feel about having a 3-year curriculum?a 12. How do you feel AHD has affected the quality of patient care?a a Question was added to interview guide as part of iterative process based on comments from previous groups
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Table 2. Demographic Data of Focus Group and Individual Interview Participants (N=32) Characteristic n (%) Male 7 (19) Post-Graduate Year 1 11 (31) 2 11 (39) 3 10 (31) Number of AHD Sessions Attended 1 2 (6) 2 6 (17) 3 8 (22) >3 16 (56) Preferred Learning Style Lecture only 0 (0) Small group, case-based 9 (28) Lecture + small group 20 (63) Other 3 (8)
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Quotation “I think the hospitalist team has really bought into AHD and are willing to cover and I'm not sure all of the sub-specialties are there yet.”
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Table 3. Themes with Illustrative Quotations Theme Aids and Barriers to Attending AHD
“The one challenge that I've seen is when you are on nights, you don't get to go.”
Curricular Content
“I was the Senior on the wards covering when the interns were gone. And that was a crazy afternoon. It was hard.” “It is nice to see that the faculty is engaged in developing the curriculum and that they want to be there.”
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Teaching
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“You’re cramming your whole day’s work into the half-day.”
“They did do a really, really nice mix of lecture and then application and then lecture and application.” “I think it is a set up for gaps in knowledge.”
Resident Well-being
“But if you miss that one day, you are missing essentially a month of teaching. “I think it is kind of therapeutic and it is refreshing to just have a chance to step away from the grind and focus on investing in your education for being a better clinician.”
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Learning and Engagement
“They are definitely more practical. They are more memorable. And definitely more applicable.” “The pagers are off. So mentally you have much more attentiveness. And, I've found myself asking quite a few more questions and being more engaged.”
“It is really hard for me to leave my colleague on the ward that is covering the service.”
“I felt like I was abandoning her up there. You just feel bad when you’re leaving somebody with a lot of stuff.”
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Resident WELL-BEING
Productive LEARNING
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Resident crosscoverage
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Teaching
Learning Climate Focus on learning Comfort of smaller group setting Peer support
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Active teaching strategies Practical & relevant content
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No clinical responsibilities + No need to return to work
Figure 1. Effects of Academic Half Day on Resident Well-Being and Learning