Evaluating Curricular Modules in the Care of Children With Medical Complexity: A Mixed-Methods Randomized Controlled Trial.

OBJECTIVE: Children with medical complexity (CMC) are a growing population, yet training in complex care varies across pediatric residency programs. The purpose of this study was 1) to evaluate the effectiveness of a curriculum for pediatric residents in improving performance in a simulated clinical scenario, and 2) to explore residents' perceived self-efficacy in caring for CMC. METHODS: A randomized controlled trial was conducted supplemented by qualitative inquiry. Pediatric residents from 2 residency programs were randomly assigned to participate in interactive modules on: 1) clinical assessment, care planning, and technological dependency or 2) noncomplex care topics. The primary outcome was mean score on an Observed Structured Clinical Examination (OSCE) of tracheostomy care. Semistructured interviews were conducted postintervention and analyzed using qualitative content analysis. RESULTS: Ninety-four eligible residents were randomized. Residents who attended all modules and the OSCE and consented to participate (intervention [n = 20] and control [n=24]) were included in the final analysis. At baseline, few (9%) reported being comfortable caring for CMC. There was no significant difference in mean OSCE score between intervention and control groups (39.0 ± 1.1 vs 38.0 ± 1.0, P = .48). Qualitative analysis revealed 3 emerging themes related to resident self-efficacy: building a system of care, navigating uncertainty, and professional identity formation. CONCLUSIONS: A standardized complex care curriculum delivered in a classroom setting did not lead to improved performance in an OSCE station despite increased resident-reported self-efficacy in approaching care for CMC. These findings highlight the need for multidimensional educational interventions and assessments in complex care.

Approach to Clinical Assessment of Children With Medical Complexity.

Introduction: General pediatricians have a major role in the care of children with medical complexity (CMC) in hospital and community settings. CMC are often affected by chronic multisystem diseases and functional limitations and may use a wheelchair or other aids for mobility. Dedicated training opportunities to perform comprehensive clinical assessments for this specialized population are lacking. Methods: We developed a module focused on special considerations for CMC history taking and physical examination that was piloted in a pediatric residency program. The 60-minute session included a video of a clinical assessment of a child in a wheelchair. The module offered suggestions for incorporating patients or standardized patients as optional activities. Target learners answered formative pre- and posttest questions to check understanding and completed a 1-minute paper to convey lessons learned. Qualitative content analysis identified themes in written responses. Results: Fifteen pediatrics residents in a single program participated in the module. Most had not received any formal training in complex care. Themes in learner knowledge of steps in a clinical encounter included defining family goals and providing anticipatory guidance. Themes from responses about anticipated changes in clinical practice included systematic and comprehensive approach to history taking, thorough examination, and importance of safe transfers. Discussion: Developed as part of a national initiative in complex care curriculum development, this module can be adapted for interprofessional learners who provide care for CMC, with the goal of enabling future members of health care teams to provide high-quality clinical assessments for CMC.

Understanding the Needs of Children With Medical Complexity.

Introduction: Children with medical complexity (CMC) are characterized by chronic conditions, functional limitations, technology dependence, and high health care utilization. There are limited formal training opportunities in the provision of complex care for pediatric residents. Methods: We developed a module to enable target learners to understand unique needs of CMC and the general pediatrician's role in creating a medical home. The module was piloted in a single pediatric residency program. The 60-minute session incorporated small-group activities and didactic instruction. Learners were given formative pre- and posttest questions to check understanding and completed a 1-minute paper to summarize anticipated changes in practice. Qualitative content analysis was used to identify themes in written responses. Results: Fifteen pediatrics residents participated in the module at a single children's hospital. Most residents had not had a complex care clinical rotation. Themes in learner knowledge of CMC included recognizing functional limitations and recurrent health care utilization. Themes from anticipated changes in practice included having less fear/anxiety when approaching care for CMC and asking about diverse areas of need, including nonmedical. Discussion: This core module was developed as part of a national systematic approach to complex care curriculum development. It has the potential to be adapted to frame a broader complex care curriculum and to be implemented with other learners in the health professions who care for this vulnerable patient population. The pilot study informed implementation in multiple residency programs, with the goal of enabling future pediatricians to provide high-quality care within a medical home for CMC.