Being and Becoming: Narrative Records of Pediatric Critical Care Clinicians.

Medical humanities initiatives have been integrated in our Pediatric Critical Care program to help clinicians make meaning of key experiences in their professional and personal journeys. In particular, narrative medicine and clinicians' writings illuminate and commemorate these journeys and increase our understanding of our profession in its full complexity. In this piece, we provide an example of a medical humanities curriculum and a selection of pieces written by several participants in it. These pieces form a collective narrative, portraying aspects of our individual and collective biography.

Resident competencies before and after short intensive care unit rotations: a multicentre pilot observational study.

PURPOSE: Residency programs need to understand the competencies developed by residents during an intensive care unit (ICU) rotation, so that curricula and assessments maximize residents' learning. The primary study objective was to evaluate the feasibility for training programs and acceptability by residents of conducting a multi-competency assessment during a four-week ICU rotation. METHODS: We conducted a prospective, multicentre observational pilot study in three ICUs. During weeks 1 and 4 of an ICU rotation, we conducted repeated standardized assessments of non-critical care specialty residents' competencies in cognitive reasoning (script concordance test [SCT]), procedural skills (objective structured assessment of technical skills [OSATS]-global rating scale], and communication skills through a written test, two procedural simulations, and a simulated encounter with a "family member". The feasibility outcomes included program costs, the proportion of enrolled residents able to complete at least one three-station assessment during their four-week ICU rotation, and acceptability of the assessment for the trainees. RESULTS: We enrolled 63 (69%) of 91 eligible residents, with 58 (92%) completing at least one assessment. The total cost to conduct 90 assessments was CAD 33,800. The majority of participants agreed that the assessment was fair and that it measured important clinical abilities. For the 32 residents who completed two assessments, the mean (standard deviation) cognitive reasoning and procedural skill scores increased between weeks 1 and 4 [SCT difference, 3.1 (6.5), P = 0.01; OSATS difference for bag-mask ventilation and central line insertion, 0.4 (0.5) and 0.6 (0.8), respectively; both P ≤ 0.001]. Nevertheless, the communication scores did not change significantly. CONCLUSIONS: A monthly multi-competency assessment for specialty residents rotating in the ICU is likely feasible for most programs with appropriate resources, and generally acceptable for residents. Specialty residents' cognitive reasoning and procedural skills may improve during a four-week ICU rotation, whereas communication skills may not.

RéSUMé: OBJECTIF: Afin que les programmes de formation et les évaluations maximisent les apprentissages des résidents, les programmes de résidence doivent comprendre quelles compétences sont développées par les résidents pendant un stage à l'unité de soins intensifs (USI). L'objectif principal de cette étude était d'évaluer la faisabilité pour les programmes de formation et l'acceptabilité par les résidents de réaliser une évaluation multi-compétences pendant un stage de quatre semaines à l'USI. MéTHODE: Nous avons réalisé une étude pilote observationnelle prospective multicentrique dans trois USI. Pendant les semaines 1 et 4 du stage à l'USI, nous avons mené des évaluations standardisées répétées des compétences des résidents non inscrits dans une spécialisation en soins intensifs en matière de raisonnement cognitif (test de concordance de script [SCT]), d'habiletés procédurales (évaluation objective structurée des compétences techniques [OSATS] - échelle d'évaluation globale), et d'habiletés de communication via un examen écrit, deux simulations d'intervention, et une rencontre simulée avec un « membre de la famille ¼. Les critères de faisabilité comprenaient les coûts du programme d'évaluation, la proportion de résidents inscrits capables de compléter au moins une évaluation en trois stations au cours de leur stage de quatre semaines à l'USI, et l'acceptabilité de l'évaluation par les résidents. RéSULTATS: Nous avons recruté 63 (69 %) des 91 résidents éligibles, et 58 (92 %) ont complété au moins une évaluation. Le coût total pour réaliser 90 évaluations était de 33 800 CAD. La majorité des participants étaient d'accord que l'évaluation était équitable et qu'elle mesurait d'importantes habiletés cliniques. Chez les 32 résidents ayant complété deux évaluations, les scores moyens (écart type) en matière de raisonnement cognitif et d'habiletés techniques ont augmenté entre les semaines 1 et 4 : différence au SCT, 3,1 (6,5), P = 0,0; différence à l'OSATS pour la ventilation au masque et l'installation d'une voie centrale, 0,4 (0,5) et 0,6 (0,8), respectivement; tous deux P ≤ 0,001. Toutefois, les scores en matière de communication n'ont pas changé de manière significative. CONCLUSION: Une évaluation multi-compétences mensuelle des résidents en spécialisation faisant un stage à l'USI est probablement réalisable dans la plupart des programmes disposant des ressources nécessaires, et elle est généralement acceptable pour les résidents. Le raisonnement cognitif et les habiletés techniques des résidents pourraient s'améliorer pendant un stage de quatre semaines à l'USI, alors que leurs compétences de communication pourraient demeurer inchangées.

A multicentre investigation of organ and tissue donation education for critical care residents.

PURPOSE: To describe critical care medicine residents' training, expertise, and skills regarding organ and tissue donation processes and procedures. METHODS: We undertook a qualitative multicentre study and employed a purposive sample of program directors, physicians, nurses, residents, and organ donation leaders from all nine academic intensive care unit (ICU) training centres (five adult, four pediatric) in Ontario (n = 71). Interviews, conducted by telephone between December 2015 and March 2016, were audio-recorded and transcribed verbatim. Data collection and analysis were performed using an iterative process and continued until saturation was achieved. RESULTS: Five main themes were identified: 1) gaps in residents' knowledge for both neurologic determination of death (NDD) and circulatory determination of death (DCD) cases; 2) commitment to the provision of organ and tissue donation training; 3) limited experiential learning (NDD and DCD); 4) challenges related to the provision of training on organ donation and need for a standardized curriculum; and 5) communication with family members. Overall, this study showed system-level gaps in training resulting from the lack of a standardized provincial curriculum on organ donation. CONCLUSIONS: Qualitative data corroborated that residents need more exposure to clinical cases, especially regarding DCD donors. A standardized education curriculum would be beneficial for all residents within the ICU. Developing a better shared understanding of the donation process will improve team communication and performance, translate into a better end-of-life experience for families, and potentially result in increased donation rates.

Validity and Feasibility Evidence of Objective Structured Clinical Examination to Assess Competencies of Pediatric Critical Care Trainees.

OBJECTIVE: The purpose of this study was to provide validity and feasibility evidence for the use of an objective structured clinical examination in the assessment of pediatric critical care medicine trainees. DESIGN: This was a validation study. Validity evidence was based on Messick's framework. SETTING: A tertiary, university-affiliated academic center. SUBJECTS: Seventeen pediatric critical care medicine fellows were recruited in 2012 and 2013 academic year. INTERVENTIONS: None. All subjects completed an objective structured clinical examination assessment. MEASUREMENTS AND MAIN RESULTS: Seventeen trainees were assessed. Simulation scenarios were developed for content validity by pediatric critical care medicine and education experts using CanMEDS competencies. Scenarios were piloted before the study. Each scenario was evaluated by two interprofessional raters. Inter-rater agreement, measured using intraclass correlations, was 0.91 (SE = 0.09) across stations. Generalizability theory was used to evaluate internal structure and reliability. Reliability was moderate (G-coefficient = 0.67, Φ-coefficient = 0.52). The greatest source of variability was from participant by station variance (40.6%). Pearson correlation coefficients were used to evaluate the relationship of objective structured clinical examination with each traditional assessment instruments: multisource feedback, in-training evaluation report, short-answer questions, and Multidisciplinary Critical Care Knowledge Assessment Program. Performance on the objective structured clinical examination correlated with performance on the Multidisciplinary Critical Care Knowledge Assessment Program (r = 0.52; p = 0.032) and multisource feedback (r = 0.59; p = 0.017), but not with the overall performance on the in-training evaluation report (r = 0.37; p = 0.143) or short-answer questions (r = 0.08; p = 0.767). Consequences were not assessed. CONCLUSION: Validity and feasibility evidence in this study indicate that the use of the objective structured clinical examination scores can be a valid way to assess CanMEDS competencies required for independent practice in pediatric critical care medicine.

The Barriers and Facilitators to Transfer of Ultrasound-Guided Central Venous Line Skills From Simulation to Practice: Exploring Perceptions of Learners and Supervisors.

UNLABELLED: PHENOMENON: Ultrasound-guided central venous line insertion is currently the standard of care. Randomized controlled trials and systematic reviews show that simulation is superior to apprenticeship training. The purpose of this study is to explore, from the perspectives of participants in a simulation-training program, the factors that help or hinder the transfer of skills from simulation to practice. APPROACH: Purposeful sampling was used to select and study the experience and perspective of novice fellows after they had completed simulation training and then performed ultrasound-guided central venous line in practice. Seven novice pediatric intensive care unit fellows and six supervising faculty in a university-affiliated academic center in a large urban city were recruited between September 2012 and January 2013. We conducted a qualitative study using semistructured interviews as our data source, employing a constructivist, grounded theory methodology. FINDINGS: Both curricular and real-life factors influence the transfer of skills from simulation to practice and the overall performance of trainees. Clear instructions, the opportunity to practice to mastery, one-on-one observation with feedback, supervision, and further real-life experiences were perceived as factors that facilitated the transfer of skills. Concern for patient welfare, live trouble shooting, complexity of the intensive care unit environment, and the procedure itself were perceived as real-life factors that hindered the transfer of skills. Insights: As more studies confirm the superiority of simulation training versus apprenticeship training for initial student learning, the faculty should gain insight into factors that facilitate and hinder the transfer of skills from simulation to bedside settings and impact learners' performances. As simulation further augments clinical learning, efforts should be made to modify the curricular and bedside factors that facilitate transfer of skills from simulation to practice settings.

Use of an error-focused checklist to identify incompetence in lumbar puncture performances.

CONTEXT: Checklists are commonly used in the assessment of procedural competence. However, on most checklists, high scores are often unable to rule out incompetence as the commission of a few serious procedural errors typically results in only a minimal reduction in performance score. We hypothesised that checklists constructed based on procedural errors may be better at identifying incompetence. OBJECTIVES: This study sought to compare the efficacy of an error-focused checklist and a conventionally constructed checklist in identifying procedural incompetence. METHODS: We constructed a 15-item error-focused checklist for lumbar puncture (LP) based on input from 13 experts in four Canadian academic centres, using a modified Delphi approach, over three rounds of survey. Ratings of 18 video-recorded performances of LP on simulators using the error-focused tool were compared with ratings obtained using a published conventional 21-item checklist. Competence/incompetence decisions were based on global assessment. Diagnostic accuracy was estimated using the area under the curve (AUC) in receiver operating characteristic analyses. RESULTS: The accuracy of the conventional checklist in identifying incompetence was low (AUC 0.11, 95% confidence interval [CI] 0.00-0.28) in comparison with that of the error-focused checklist (AUC 0.85, 95% CI 0.67-1.00). The internal consistency of the error-focused checklist was lower than that of the conventional checklist (α = 0.35 and α = 0.79, respectively). The inter-rater reliability of both tools was high (conventional checklist: intraclass correlation coefficient [ICC] 0.99, 95% CI 0.98-1.00; error-focused checklist: ICC 0.92, 95% CI 0.68-0.98). CONCLUSIONS: Despite higher internal consistency and inter-rater reliability, the conventional checklist was less accurate at identifying procedural incompetence. For assessments in which it is important to identify procedural incompetence, we recommend the use of an error-focused checklist.

Cased-based education rounds-the eternal heart of an international training program.

Case-based teaching or "Morning Rounds" have been used in medical education for more than a century and remain a cornerstone for teaching in many training programs. Our Pediatric Critical Care Medicine (PCCM) program was established forty years ago and has retained this form of teaching since its inception. Case-based rounds have consistently had the highest evaluation of all curricula in our program. Here we review the history of how these rounds were introduced in medical education, provide data from the learners' evaluation of these case-based rounds, and discuss the strengths and potential drawbacks of this form of teaching from an educational theories perspective with the hope that they can be used by other Pediatric Critical Care training programs.

Pediatric Critical Care Fellow Perception of Learning through Virtual Reality Bronchoscopy.

Background: Virtual reality (VR) simulators have revolutionized training in bronchoscopy, offering unrestricted availability in a low-stakes learning environment and frequent assessments represented by automatic scoring. The VR assessments can be used to monitor and support learners' progression. How trainees perceive these assessments needs to be clarified. Objective: The objective of this study was to examine what assessments learners select to document and receive feedback on and what influences their decisions. Methods: We used a sequential explanatory mixed methods strategy. All participants were pediatric critical care medicine trainees requiring competency in bronchoscopy skills. During independent simulation practice, we collected the number of learning-focused practice attempts (scores not recorded), assessment-focused practice (scores recorded and reviewed by the instructor for feedback), and the amount of time each attempt lasted. After simulation training, we conducted interviews to explore learners' perceptions of assessment. Results: There was no significant difference in the number of attempts for each practice type. The average time per learning-focused attempt was almost three times longer than the assessment-focused attempt (mean [standard deviation] 16 ± 1 min vs. 6 ± 3 min, respectively; P < 0.05). Learners perceived documentation of their scores as high stakes and only recorded their better scores. Learners felt safer experimenting if their assessments were not recorded. Conclusion: During independent practice, learners took advantage of automatic assessments generated by the VR simulator to monitor their progression. However, the recording of scores from the simulation program to document learners' trajectory to a set goal was perceived as high stakes, discouraging learners from seeking supervisor feedback.

Through the looking glass: qualitative study of critical care clinicians engaging in humanities.

PURPOSE: Critical care medicine is facing an epidemic of burnout and consequent attrition. Interventions are needed to re-establish the medical field as a place of professional growth, resilience, and personal well-being. Humanities facilitate creation, reflection, and meaning-making, holding the promise of personal and community transformation. This study aimed to explore how clinicians engage with a humanities program, and what role and impact do the humanities play in their individual and collective journey. METHODS: This is a qualitative study employing a phenomenological approach. Participants were faculty and trainees who participated in the program. Data consisted of (a) 60-h observations of humanities evenings, (b) more than 200 humanities artifacts brought by participants, and (c) 15 in-depth participant interviews. Data were analyzed inductively and reflectively by a team of researchers. RESULTS: Participants were motivated to engage with the humanities curriculum because of past experiences with art, identifying a desire to re-explore their creativity to make meaning from their clinical experiences and a wish to socialize with and understand their colleagues through a different lens. The evenings facilitated self-expression, and inspired and empowered participants to create art pieces and re-engage with art in their daily lives. More importantly, they found a community where they could be vulnerable and supported, where shared experiences were discussed, emotions were validated, and relationships were deepened between colleagues. CONCLUSIONS: Humanities may impact resilience and personal and community well-being by facilitating reflection and meaning-making of challenging clinical work and building bonds between colleagues.

The Gift of Life: Interprofessional Organ Donation Curriculum in Pediatric Critical Care.

Background: The number of patients awaiting organ transplantation is high, particularly in Pediatrics, in which available organs are scarce. To maximize organ donation opportunities and to provide quality end-of-life care, clinicians from all professions must be familiar with the process. There continues to be important gaps in core competencies regarding organ donation, including donor criteria and eligibility, timing of referral to organ procurement organizations, neurological determination of death, donation after cardiocirculatory death, and donor management. These gaps affect healthcare providers across multiple professions and are significant barriers to donation. Objective: We describe an interprofessional curriculum that is designed to teach Pediatric Critical Care Medicine (PCCM) clinicians about the process of organ donation and supporting the families through that process. The approach of families is the purview of organ procurement organization, and the support of the families through the process remains with PCCM clinicians. Methods: Kern's six-step approach to curriculum development was used to develop, implement, and evaluate an interprofessional curriculum on organ donation in PCCM for physicians, nurses, and respiratory therapists. Results: Problem formulation and both general and targeted needs assessments were performed through a comprehensive literature review, including review of national guidelines and Royal College of Physicians and Surgeons of Canada training objectives. Learning objectives and educational strategies were then outlined using two educational frameworks. After implementation, the curriculum was evaluated using learner self-assessments with a retrospective pre-post design. Conclusion: After identifying educational gaps contributing to barriers to organ donation, an interprofessional curriculum was developed to increase competency in multiple aspects of organ donation, including team communication and collaboration, with the ultimate goal of promoting a culture of donation while ensuring it is part of quality end-of-life care.

Ignorance Isn't Bliss: We Must Close the Machine Learning Knowledge Gap in Pediatric Critical Care.

Pediatric intensivists are bombarded with more patient data than ever before. Integration and interpretation of data from patient monitors and the electronic health record (EHR) can be cognitively expensive in a manner that results in delayed or suboptimal medical decision making and patient harm. Machine learning (ML) can be used to facilitate insights from healthcare data and has been successfully applied to pediatric critical care data with that intent. However, many pediatric critical care medicine (PCCM) trainees and clinicians lack an understanding of foundational ML principles. This presents a major problem for the field. We outline the reasons why in this perspective and provide a roadmap for competency-based ML education for PCCM trainees and other stakeholders.

Mental Practice as an Additional Step Before Simulation Practice Facilitates Training in Bronchoscopic Intubation.

BACKGROUND: Learning bronchoscopy is challenging for novices, as it requires navigation in a 3-dimensional space under 2-dimensional viewing conditions and execution of complex motor skills with an unfamiliar instrument. Mental practice exercises are based on repeated visualization of motor actions without physically performing them, thereby promoting the learning of skills. We aimed to evaluate whether a teaching intervention including mental practice exercise modules for the acquisition of bronchoscopy skills improves fiberoptic intubation performance of novice learners. METHODS: In this prospective cohort study, 24 pediatric intensive care trainees and respiratory therapists participating in a bronchoscopy learning curriculum in 2016-2017 attended a theoretical lecture followed by self-guided learning. Subsequently, the learners were randomly assigned to either participating in a teaching intervention including mental practice exercises or not (control group). The primary outcome was time to complete their first bronchoscopic intubation using a virtual reality simulator. Secondary outcomes were the occurrence of "red outs" (ie, the anatomy could no longer be visualized) or collisions with the airway wall. Bayesian Poisson Mixture models were used to estimate the effect of the intervention on outcomes. Furthermore, participation in the teaching intervention was examined in short interviews and with descriptive thematic analysis. RESULTS: Subjects in the intervention group completed the bronchoscopy on average 1.2 times faster (rate ratio 1.2 [95% credible intervals 1.1-1.3]). The posterior probability that the teaching intervention reduced the occurrence of "red outs" by more than half was 86%. No differences were found regarding the odds of colliding with the airway wall. Everyone except 1 trainee in the mental practice group engaged with and found the mental practice modules helpful. CONCLUSIONS: A teaching intervention including mental practice exercises represents a valuable additional learning strategy promoting the performance and complex skill acquisition of novice learners in the initial stages of learning bronchoscopy procedures.

Who am I? Narratives as a window to transformative moments in critical care.

Critical care clinicians practice a liminal medicine at the border between life and death, witnessing suffering and tragedy which cannot fail to impact the clinicians themselves. Clinicians' professional identity is predicated upon their iterative efforts to articulate and contextualize these experiences, while a failure to do so may lead to burnout. This journey of self-discovery is illuminated by clinician narratives which capture key moments in building their professional identity. We analyzed a collection of narratives by critical care clinicians to determine which experiences most profoundly impacted their professional identity formation. After surveying 30 critical care journals, we identified one journal that published 84 clinician narratives since 2013; these constituted our data source. A clinician educator, an art historian, and an anthropologist analyzed these pieces using a narrative analysis technique identifying major themes and subthemes. Once the research team agreed on a thematic structure, a clinician-ethicist and a trainee read all the pieces for analytic validation. The main theme that emerged across all these pieces was the experience of existing at the heart of the dynamic tension between life and death. We identified three further sub-themes: the experience of bridging the existential divide between dissimilar worlds and contexts, fulfilling divergent roles, and the concurrent experience of feeling dissonant emotions. Our study constitutes a novel exploration of transformative clinical experiences within Critical Care, introducing a methodology that equips medical educators in Critical Care and beyond to better understand and support clinicians in their professional identity formation. As clinician burnout soars amidst increasing stressors on our healthcare systems, a healthy professional identity formation is an invaluable asset for personal growth and moral resilience. Our study paves the way for post-graduate and continuing education interventions that foster mindful personal growth within the medical subspecialties.

More Is Not Always Better in Simulation. Learners' Evaluation of a "Chest Model".

Background: Fidelity in simulation is an important design feature. Although it is typically seen as bipolar (i.e., "high" or "low"), fidelity is actually multidimensional. There are concerns that "low fidelity" might impede the immersion of learners during simulation training. "Locally built models" are characterized by decreased cost and reduced "structural" fidelity (how the simulator looks) while satisfying "functional" fidelity (what the simulator does). Objective: To 1) describe the use of a locally built chest tube model in building a mastery-based simulation curriculum and 2) describe evaluation of the model from learners in different stages and contexts. Methods: The model was built on the basis of key functional features of the assigned training task. A curriculum that combined progressive difficulty and opportunities for deliberate practice and mastery was developed. An analysis of the learner's survey responses was performed using SAS studio (SAS Software). Results: We describe the process of creating the chest tube model and a curriculum in which the model is used for increasing levels of difficulty to reach skill mastery. Learners at different stages and in different contexts, such as practicing physicians and trainees from developed and developing countries, evaluated the model similarly. We provide validity evidence for the content, response process, and relationship with other variables when using the model in the assessment of chest tube insertion skills. Conclusion: As demonstrated in our chest tube critical care medicine curriculum, the locally built models are simple to build and feasible to use. Contrary to current thinking that low-fidelity models might impede immersion in simulation training for experienced learners, the survey results show that different learners provide very similar evaluations after practicing with the model.

Using Learning Curves to Identify and Explain Growth Patterns of Learners in Bronchoscopy Simulation: A Mixed-Methods Study.

PURPOSE: Learning curves can illustrate how trainees acquire skills and the path to competence. This study examined the growth trajectories of novice trainees while practicing on a bronchoscopy virtual reality (VR) simulator compared with those of experts. METHOD: This was a sequential explanatory mixed-methods design. Twenty pediatric subspecialty trainees and 7 faculty practiced with the VR simulator (October 2017 to March 2018) at the Hospital for Sick Children, Toronto, Canada. The authors examined the relationship between number of repetitions and VR outcomes and patterns of growth using a growth mixture modeling. Using an instrumental case study design, field notes and semistructured interviews with trainees and simulation instructor were examined to explain the patterns of growth. The authors used a constant comparative approach to identify themes iteratively. Team analysis continued until a stable thematic structure was developed and applied to the entire data. RESULTS: The growth mixture model identified 2 patterns of growth. A slower growth included learners that had inherent difficulty with the skill, did not integrate the knowledge of anatomy in simulation practice, and used the simulator for simple repetitive practice with no strategy for improvement in between trials. The faster growth included learners who used an adaptive expertise approach: integrating knowledge of anatomy, finding flexible solutions, and creating a deeper conceptual understanding. CONCLUSIONS: The authors provide validity evidence for use of growth models in education and explain patterns of growth such as a "slow growth" with a mechanistic repetitive practice and a "fast growth" with adaptive expertise.

Exploring How Pediatric Residents Develop Adaptive Expertise in Communication: The Importance of "Shifts" in Understanding Patient and Family Perspectives.

PURPOSE: Communication with patients and families can be complex, especially in challenging discussions. To communicate effectively, expert physicians must often use flexible approaches. This innovative use of knowledge to handle complexity is an essential capability of adaptive expertise. Despite its importance for effective communication and implications for medical education, little is known about how adaptive expertise develops in trainees. The purpose of this study was to explore how pediatric residents developed adaptive expertise in communication. METHOD: A constructivist grounded theory study, using observations of physician-patient communication and semistructured interviews as data sources and purposeful sampling of 10 pediatric subspecialty residents at the University of Toronto, was conducted in 2016-2017. Data collection and analysis occurred iteratively, and themes were identified through the research team's constant comparative analysis. RESULTS: Residents navigated challenging discussions with patients and families by enabling them to express their own narratives and integrating these with their medical knowledge to provide care. At times, a "shift" in the residents' understanding of the families' perspectives was needed to effectively navigate the discussion. Residents used this shift purposefully to create new communication strategies, resulting in an opportunity for learning. CONCLUSIONS: "Shifts" are defined as adjustments in the resident's understanding of a family's perspective that affect clinical care. Analysis suggests that these "shifts" can be understood to support development of adaptive expertise. The workplace learning environment promoted this development by providing opportunities that prepared residents for future learning through active experimentation, offering multiple perspectives and enhancing deeper conceptual learning.