Research article
Open Access

Creating a culture of lifelong learning among Med-Peds Residents

Siobhán O'Keefe[1], Mary Catherine Turner[2], Nathan Andrew Brinn[3], Dale Newton[2]

Institution: 1. Children's Hospital Colorado, University of Colorado, 2. East Carolina University & Vidant Health, 3. University of South Florida
Corresponding Author: Dr Siobhán O'Keefe ([email protected])
Categories: Educational Strategies, Teaching and Learning, Postgraduate (including Speciality Training), Curriculum Evaluation/Quality Assurance/Accreditation
Published Date: 12/04/2018

Abstract

Introduction

Institutional Culture is difficult to change but is imperative to the quality of physicians at an institution and its trainees.

Background/Rationale

Not all physicians practice life-long learning. Barriers include emphasis on clinical productivity, ineffective online searching, inadequate personal initiative and institutional culture. We were concerned that our institutional culture did not routinely stimulate the dynamic discussion of recent literature. To impact this culture, we implemented a lifelong learning lecture series for combined medicine-pediatrics (Med-Peds) physicians.

Methods

Articles were selected from the American Academy of Pediatrics Grand Rounds and American College of Physicians Journal Clubs. 8-10 Articles were reviewed in “rapid fire’ style and heated discussion was encouraged. Participants completed tests assessing knowledge pertaining to the articles to quantify their engagement.

Results

120 articles were reviewed during 15 lectures. 37 out of a potential 40 physicians participated. Participants answered a mean of 11% more questions correctly on short term recall (p=0.0026) and on long term recall (p= 0.0600) when compared to their baseline knowledge. When comparing the questions that pertained to lectures the participants attended versus those they did not attend participants answered 7% more questions correctly on short term recall ( p=0.0800) and long term recall ( p=0.1200).

Conclusions

Culture is difficult to measure. The improved correct responses to questions about the papers presented suggests that the participants did engage in the discussion of the articles. Given the nature of Med-Peds training, culture change has the potential to affect the culture within both departments.

Keywords: Evidence based medicine; MedPeds; Lifelong learning

Introduction

The ability to practice lifelong learning and interpret current medical literature is crucial to physician development according to the milestones outlined for pediatrics and internal medicine by the American College of Graduate Medical Education. 1-2 It is also essential for certification with the American Boards of Pediatrics and Internal Medicine. 3-4 Unfortunately some physicians do not meaningfully engage the literature in the context of their patient care. 5-8  Barriers cited include lack of access to medical information, poor skills in searching information resources, time constraints, emphasis on clinical productivity, lack of personal initiative, team dynamics, and institutional culture. 7-8  Medical innovation and research continues to rapidly evolve making it arduous for physicians to stay up to date with current medical evidence. For combined internal medicine and pediatrics (Med-Peds) physicians this challenge is doubled as they attempt to absorb the literature from two major specialties.

Journal clubs are widely used in residency programs to teach evidence based medicine and promote lifelong learning. Advantages include ease of implementation, adaptability, faculty comfort, minimal preparation time, and resident-centered approach to teaching.  Improvements have been found to be rather small and short term with regards to knowledge learned about clinical epidemiology and biostatistics, critical appraisal skills, self-reported reading habits and use of the medical literature.9-10

Other novel approaches have been used to incorporate lifelong learning into residency curriculums and have had some encouraging outcomes. Examples include but are not limited to a supplementary rotation where the resident developed critically appraised topics based on clinical questions assigned by an inpatient team, an electronic database of clinical questions and the related medical evidence, a database searching tutorial, a laboratory experience focused on problem solving and evidence-based medicine skill development and an evidence based medicine curriculum. 11-15

Educators who have tried to inject enthusiasm for lifelong learning and evidence based medicine into resident training realize that changing institutional culture is an important but daunting task. One author emphasizes that changing attitudes towards incorporating evidence-based medicine into our daily lives as physicians as an imperative first step but is the hardest thing to do. 16

At our residency we were concerned that our institutional culture did not routinely stimulate the dynamic discussion of recent literature. In an attempt to impact this culture, we implemented a lifelong learning curriculum for Med-Peds residents. The major goal of this intervention was to stimulate a culture of lifelong learning among our Med-Peds physicians and increase their confidence in their ability to apply current medical literature to the care they provide to patients. To our knowledge such lifelong learning sessions have not been described specifically targeted for Med-Peds physicians.

Methods

This was a prospective cohort study. All post-graduate level (PGY) Med-Peds residents and core Med-Peds faculty were invited to participate in the curriculum. The educational intervention was a lecture series given at our weekly Med-Peds noon conferences.  Landmark articles were selected from American College of Physicians (ACP) journal club and American Academy of Pediatrics (AAP) grand rounds. 17-18 They were selected by the first author according to their relevance to daily patient care at our institution. Summaries of 8-10 articles were individually reviewed in “rapid-fire” style. A clinical vignette was described prior to each paper and an audience response system Turning Point was used to stimulate interest in the topic and attain feedback from the audience about their current approach to such a clinical situation. After the findings of the study were revealed, an energetic discussion was encouraged to gather opinions about how the study did or did not change the status quo of institutional clinical practice. 

At each session the resident physicians filled out a questionnaire.  The questions were true/false questions assessing knowledge regarding the outcomes of landmark articles discussed at that session. The interval between each session was usually 4-8 weeks and each questionnaire also included questions regarding the session prior to the current session – these questions were intended to represent “short term recall”.  In the spring of each year the residents filled out a questionnaire including all of the previous questions for the last year which was recorded as “long-term recall”.

Participation in the conference and the survey was voluntary. Survey responses were anonymous. The residents and faculty assigned themselves an anonymous alias so that we could track individual answers to the questions over time but this alias was not in any way linked to an identifying information that would link that individual to their survey responses. The Institutional Review Board at East Carolina University approved our study under reference number UMCIRB 12-001487.

Results

The lecture series started in August 2012 and has continued through October 2015. In total 15 sessions were held which included one pilot session. Initially we reviewed 10 articles per session but in order to facilitate more time for the discussions between each study we decreased this to on average 8 studies per session. There was equal balance between pediatric and adult studies 19-139. Studies reviewed were very diverse with regard to content as can be seen in Table 1.

 

Table 1 – Summary of Studies Reviewed during Course 19-139

Journal

Relevant to Pediatrics

Relevant to Medicine

Acad Emerg Med

Dexamethasone in Acute Asthma

Inhaled steroids in acute asthma

 

Age Ageing

 

Non Invasive Ventilation in Elderly.

Am J Gastroenterol

 

Proton Pump Inhibitors in Clostridium Difficile

Rifaximin and Hepatic Encephalopathy

Am J Kidney Dis

Risk factors for CKD in adolescents

 

Am J Med Genet

DiGeorge Syndrome & behavior

 

Am J Public Health

Gun Related Violence

 

Am J Prev Med

Associations of Appropriate Car Seat Use.

 

Am J Roentgenol

Imaging in Appendicitis

 

Am J Sports Med

Ankle braces and Injury in Adolescents

 

Ann Intern Med

 

INR monitoring and warfarin.

Statins and Mortality

Screening for Lung Cancer in Smokers.

Antiplatelet agents and Stroke

Ann Rheum Dis

 

Rheumatoid Arthritis and cardiovascular risk.

Arch Dis Child

Cardiac Testing in ALTE.

 

Arch Pediatr Adolesc Med

Growth percentiles and risk of childhood obesity.

 

Arch Intern Med

BP goal and diabetes

BP Goal and diabetes

Br J Psychiatry

 

Agitation in Dementia

Br J Sports Med

Sickle Cell Trait and sudden death

 

BMJ

Intravenous Bolus Fluid Rate in Children

 

Depression in Elderly patients

Hypnotics and Prognosis

Glucose Self-Monitoring in Diabetes.

DPP-4 Inhibitors and Diabetes.

Risk of Venous thrombosis and contraception.

Smoking Cessation

Caries Res

Caries in Children.

 

CADTH Therapeutic Review

 

Disease Modifying Agents Multiple Sclerosis.

Circulation

Congenital Heart Disease and psychiatric disorders

Pulmonary Artery Hypertension

NSAIDS and Cardiovascular risk

Clin Infect Dis

Measles Vaccine Timing

Pediatric Clostridium Difficile

 

Cochrane Database Syst Rev

Influenza Treatment

Spacer versus Nebulizer  in Asthma

Reduced Salt Diet and Mortality

A1C goal and Type 2 Diabetes

Inpatient Geriatric Assessment and Prognosis

Smoking Cessation x 2 studies

Migraine Management

Opioids and Osteoarthritis.

Crit Care Med

Risk factors of Sedation in Children

Influenza in Children.

 

Eur Heart J

 

Secretagogues versus Metformin

ACE inhibitors/ARB treatment

Contrast Induced Nephropathy

Gastroenterology

 

Anticoagulants and GI bleed Risk.

J Adol Health

Obesity and Eating disorders

 

J Am Coll Cardiol

 

High Sensitivity Troponin

J Am Soc Nephrol

 

Timing of Anti-hypertensive Medications.

J Am Geriatr Soc

 

Prognosis in Geriatric Patients

JAMA &

JAMA Pediatrics

Febrile Seizures and Immunizations.

Vaccination in Children with JIA

Hypoxia and Bronchiolitis Childhood Obesity x 2 studies

Pertussis Vaccination

Insulin Dose in DKA

Osteomyelitis Management

 

Migraine Treatment

In- Hospital Resuscitation prognosis

Prognosis in Dialysis Patients

Length of Steroid Treatment in COPD.

Fluid and Salt intake in Heart failure

Gabapentin for Alcoholism

Ablation for Atrial Fibrillation.

Shoulder pain and Rotator Cuff disease

J Allergy Clin Immunol

Inhaled Corticosteroids and Growth

Peanut Allergy

Introduction of Egg in Infants

Steroids and Acute Rhinosinusitis

 

J Clin Endocrinol Metab

Thyroid Nodule Management

 

J Infect Dis

Epidemiology Viruses

 

J Neurol Neurosurg Psychiatry

 

Parkinson’s Disease and Prognosis

J Neurosurg

Shunt Failure in Hydrocephalus

 

J Ped Gastroenterol Nutr

Probiotics and Pediatric Gastroenteritis

 

J Ped Surg

Penicillin Allergy

 

J Rheumatol

Biologics for Treatment of JIA.

 

Lancet

Strep Pharyngitis Diagnosis

Kawasaki’s Treatment

Radiation Risk in Pediatrics

Statins and Prognosis

Stroke and T-PA

Screening for Diabetes

Newer Anticoagulants and Atrial Fibrillation.

N Engl J Med

Neonatal Herpes Suppressive therapy

Midazolam in Acute Seizure Treatment

Neonatal HIV

Treatment of Head Lice

Pediatric Obstructive Sleep Apnea
Scoliosis Management

Prophylaxis for Febrile UTI

Enterovirus Vaccine.

Introduction of Peanut to infants

Out of Hospital Cardiac Arrest in Children

HIV and Acute TB Treatment

N-Acetyl Cysteine and Alcoholic Hepatitis

Alzheimer’s Dementia Treatment

Contraception and Thrombosis

Fluids in Sepsis

Sciatica and MRI

Transfusion in Acute GI Bleed

Treatment of Meniscal Tears.

Treatment of Rheumatoid Arthritis.

Antibiotic Choice in Pneumonia.

Sepsis Management

Neurology

 

First Seizure in Adults

Pediatrics

Direct Hyperbilirubinemia in Newborn

Bacteremia in Newborn

Fever in Newborn

DKA Treatment and Cerebral Edema

Comorbidities of ADHD

Ultrasound for Vesicoureteral Reflux

Adolescent Post-Partum Depression

 

Pediatr Dermatol

Infantile Hemangiomas and Propranolol

 

Pediatr Infect Dis J

Antibiotics and E-Coli 0157 Infection

 

Rheumatology

Intra-articular Corticosteroids for JIA

 

Br J Geriatr Pract

 

Long term Benzodiazepine Use

J Rheumatol

Biologics for Treatment of JIA.

 

 

In total we discussed 120 studies relevant to the practice of Med-Peds. Test data was not analyzed for the 2 sessions in 2015 so in total we had test data on 108 articles reviewed. 37 (33 residents and 4 faculty) out of a potential 40 participants submitted answers to some of the knowledge tests at least once. Because the physicians recorded a unique identifier we were able to analyze each individual’s performance and change over time. We had comparative data for short term recall for 20 out of the 37 participants and long term recall for 28 out of 37 participants pertaining both to lectures they attended and those they did not attend.

 

Table 2

Class

Performance in Knowledge test ( Mean % correct) by Class

Not Present at Lectures

                   Present at Lectures

Short-Term Recall

Long Term Recall

Pre-Test

Short-Term Recall

Long Term Recall

Faculty

69%

74%

68%

68%

73%

MP2013

52%

50%

63%

70%

64%

MP2014

63%

58%

60%

73%

64%

MP2015

57%

60%

58%

66%

60%

MP2016

61%

63%

58%

71%

71%

MP2017

56%

57%

45%

53%

58%

MP2018

39%

56%

54%

 

80%

Overall

56%

61%

58%

68%

67%

 

Participants who attended the lectures answered a mean of 11% more questions correctly on short term recall (p=0.0026) and on long term recall (p=0.0600) when compared to their baseline knowledge. When comparing the questions that pertained to lectures the participants attended versus those they did not attend participants answered 7% more questions correctly on short term recall (p= 0.0800) and long term recall (p=0.1200). P values were calculated using matched pairs t-tests and these are the values reported. We also reached the same conclusions using the Wilcoxon test.

 

Table 3

 

Participants

Differences in % Correct in Knowledge Test by Individual

Recall From Pretest When Present

Recall Present Versus Not Present

Short Term

Long Term

Short Term

Long Term

MP 2013a

23

 

 

 

MP 2013b

11

12

14

 

MP 2014a

12

 

 

17

MP 2014b

3

10

3

22

MP 2014c

21

17

4

27

MP 2014d

15

-15

5

-30

MP 2014e

23

12

24

8

MP 2015a

10

13

6

10

MP 2015b

17

16

13

8

MP 2015c

-11

-11

-25

-4

MP 2015d

33

24

27

-6

MP 2015e

-10

-31

20

8

MP 2016a

19

17

6

5

MP 2016b

6

 

-1

 

MP 2016c

17

16

20

5

MP 2016d

26

37

26

29

MP 2016e

-12

14

-7

16

MP 2016f

 

10

 

5

MP 2017a

32

46

36

10

MP 2017b

17

23

0

8

MP 2017c

 

 

 

8

MP 2017d

-25

-37

-25

-27

MP 2018a

 

12

 

32

MP 2018b

 

 

 

39

MP 2018c

 

 

 

31

MP 2018d

 

 

 

-21

Faculty a

10

10

-10

-10

Faculty b

 

 

 

19

Faculty c

 

28

 

33

Faculty d

 

-19

 

-10

Mean

+11*

+11**

+7$

+7$$

* Percent correct increase from pretest to short term recall when participants present. P=0.0026

** Percent correct increase from pretest to long-term recall when participants were present P=0.0600

$ Increase in percent correct when participants present versus not present (short term recall) p=0.0800

$$ Increase in percent correct when participants present versus not present (long term recall) p=0.1200

 

Discussion

High quality medical education is determined in large part by the institutional educational culture. Clinical productivity and documentation, billing and general service provision continues to increase the time pressures on physicians. The motivation to continuously review recent literature and take the time to discuss findings with colleagues can be overwhelmed by service needs. This is especially true for institutions like ours that serve a large volume of high-acuity patients, the majority of whom are socioeconomically disadvantaged. For Med-Peds physicians the challenge is increased by the sheer volume of literature from two disciplines and perhaps decreased confidence to interpret the literature in comparison to their categorical colleagues.

Culture is difficult if not impossible to measure. One encouraging outcome was that the Med-Peds physicians who attended lectures had a trend towards better knowledge of the content of the papers discussed when compared to those who did not attend the lectures and this was sustained over time.

Many residencies (including our own) usually provide formal teaching according to systems and topics. However patient care is much more haphazard and diverse than that. Our curriculum reflects the diversity of daily Med-Peds patient care which may increase enjoyment, participation and recall. Likewise lectures in residency often focus on generic review of topics, lack interactivity and are very presenter dependent. This kind of rapid-fire but case-based format focuses more on management and with the potential to impact daily clinical decision making.  

While we do not have any objective evidence of a change in behavior in our physicians we anecdotally did feel a palpable change in the culture. During the lectures residents and faculty alike voiced their opinions about the status quo of clinical practice and how particular papers did or did not affect their likelihood of changing their practice. Quite often the discussions about the paper would grow tangents in other directions leading to richer conversation about the evidence behind how we practice. The authors also noted both in clinic and on the wards that Med-Peds residents were including more information gained from the literature into their management plans and documentation.

Other weaknesses of our study included that we failed to ensure that every participant that attended the lecture actually filled out the test questions – this could in turn result in some residents who attended the lectures being incorrectly placed in the “not present” group. However correction of this error would have made the results stronger. Also physicians were given the pre-test before the lecture but it was not picked up until the end so they could have filled out answers during the lecture. This would have resulted in some of the answers being incorrectly recorded as “baseline knowledge”. Again correction of this error would have just made our results stronger. Another weakness includes the variability in the time interval between each lecture and the subsequent “short term recall” and “long term recall” questionnaires. On average the “short term recall” questions were 4-8 weeks after the lecture but this was not standardized and sometimes was longer than this. Similarly, the “long term recall” questionnaires were filled out in the spring which was more than 8 months after some of the lectures but only a few months after some of the more recent lectures.

During evaluation of our curriculum we thought about possible future steps to address our overall goal of stimulating a culture of lifelong learning from the standpoint of a Med-Peds community. As the volume and complexity of medical literature continues to increase, a published Med-Peds journal club summarizing landmark papers from both medicine and pediatrics could be helpful in providing a resource for Med-Peds physicians.  Additionally, other specialties such as Emergency medicine have developed podcasts where the speakers interact together in a fun entertaining fashion while they contemporaneously review new studies relevant to their specialty and debating the relevance of the study to real world practice.141 A similar idea could be very beneficial to Med-Peds physicians with the material directed at our practice.

Conclusion

We succeeded in creating a lecture series session that encouraged lifelong learning and the use of evidence based medicine by reviewing articles with high clinical impact in an interactive enjoyable fashion with our Med-Peds residents and faculty.

Take Home Messages

Notes On Contributors

Siobhán O'Keefe was a clinical assistant professor and the associate MedPeds program director at East Carolina University during the time of the study. She is currently completing a pediatric critical care fellowship at Colorado Children's Hospital.

Mary Catherine Turner was a faculty member during the time of the study and is the current MedPeds Program director  at East Carolina University

Nathan Andrew Brinn was the MedPeds program director at East Carolina University at the time of the study and is currently a clinical associate professor at University South Florida.

Dale Newton was a clinical professor and a associate program director of the MedPeds residency program at East Carolina University at the time of the study. He is currently retired and enjoying time with his family.

Acknowledgements

The authors would like to thank all of the MedPeds residents that we have had the pleasure of working with at East Carolina University over the years and during the period of the study. Your enthusiasm, work ethic, warmth and comradry made it a pleasure to work with you.

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Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Ken Masters - (10/05/2019) Panel Member Icon
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An interesting article on creating a culture of lifelong learning among Med-Peds Residents. The authors have nicely laid out the background in the literature and the problems facing physicians that prevent staying current with the literature and so maintaining their expertise through life-long learning. The study is reasonably well described.

Weaknesses of the paper:
• Table 1 is interesting, but too broad. I see that the authors have taken the trouble to include all the articles in the bibliography, and are to be commended on that. They should, however, have tied them into Table 1 so that the readers could more easily match paper to topic. This would have simultaneously solved the problem of knowing how many papers were assigned to each topic.
• A real weakness of the paper is in the Discussion, in which the authors do discuss their findings, but fail to relate them back to the literature (where they do talk about concepts that are possibly from the literature, they fail to cite any literature on the topic.)

Small issue:
• The statistical tests used should be given in the Methods, not the Results.

So, an interesting and somewhat useful paper that, with just a little more care, could have been much stronger.
Peter Dieter - (30/04/2018) Panel Member Icon
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Institutional culture is difficult to change and changes are even more difficult to measure. The authors used lifelong learning as a culture and implemented a lecture in the noon session reviewing several articles in order to change and measure the lifelong learning culture of physicians. Participation was voluntary. After three years of the project they „could not get any objective evidence of a change in the behavior of the physicians.
The project has many weaknesses: participation was voluntary and had no benefit on the career of the physicians; number, quality and difficulty of the articles per duration of the noon session is not presented; it was not controlled if all participants filled out the pre-test given before the session and the questionnaire at the end of the session; the time intervals between the sessions was not constant.
The article might be interested for colleagues who are interested in supporting changes of institutional/personal culture.