Reflections on year one of a new residency program: Lessons for future leaders from residents and educators.

This article was migrated. The article was marked as recommended. As the number of graduating medical students increases, the number of primary care residency positions is not keeping pace. One solution to this problem is the creation and accreditation of new residencies, although there is little literature describing the perspectives of the residents and educators who found new programs. Seven out of ten resident physicians who served as the inaugural interns in a new residency training program in pediatrics provide their reflection on the distinctive perspective they had from this experience. They have identified consensus themes in topic areas of strengths, challenges, and lessons learned from training in a new program. Themes applying to strengths of participating in a new residency training program were the opportunity to shape the program, individualized learning experience, and enthusiastic faculty. Challenges of a new program included missing upper level residents, diverse faculty expectations, and morale. Themes under lessons learned included resident engagement, expectations and feedback, and wellness. Each theme was then considered in the context of the medical education literature, underscoring the important balance that new program leaders must strike between structure and flexibility. This inaugural resident class has identified key challenges and opportunities to inform education leaders who are planning new GME training programs.

Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty.

OBJECTIVE: To identify factors that influence faculty to promote or reduce the expression of autonomy for pediatric hospital medicine (PHM) fellows and describe behaviors faculty employ to support fellow autonomy in the clinical setting. METHODS: This was a multicenter, qualitative study using semistructured interviews with core faculty in PHM fellowships. Data were transcribed verbatim and analyzed using a phenomenological approach. Each transcript was coded independently by 2 trained reviewers who then met to reconcile differences. Codes were identified using an iterative approach and organized into themes. Investigators engaged in peer debriefing during data collection, and member checking confirmed the results. RESULTS: Interviews were conducted December 2016 to January 2017 with 20 faculty from 5 PHM fellowships. Most participants were female (12, 60%) and assistant (13, 65%) or associate (6, 30%) professors. Data analysis yielded 6 themes. Themes reflect the importance of faculty experience, style, and approach to balancing patient care with education in the provision of autonomy for PHM fellows. Faculty appreciation for the role of autonomy in medical education, investment in their roles as educators, and investment in PHM fellowship training are also influential factors. Finally, fellow clinical, educational, leadership, and communication skills influence the provision of autonomy. Faculty employ various levels of supervision, scaffolding techniques, and direct observation with feedback to support fellow autonomy. Professional development was considered essential for developing these skills. CONCLUSIONS: We identified 6 themes related to faculty provision of autonomy to PHM fellows, as well as strategies employed by faculty to support fellow autonomy.

Teaching Conflict Resolution in Medicine: Lessons From Business, Diplomacy, and Theatre.

Introduction: Disagreement and conflict are inevitable among members of clinical teams, as well as with patients and families during the course of medical care. Despite the importance of physicians needing to negotiate and resolve conflicts, best practices for teaching these skills have not been established in a clinical setting. Methods: We developed teaching tools based on a conflict resolution model from the business world, emphasizing team dynamics and employing a structured, hierarchical approach to conflict resolution that preserves interpersonal relationships. We employed lessons from diplomacy and improvisational theatre to underscore nonverbal cues that improve communication during conflict. We prepared instructions for teaching conflict management and conflict resolution styles, small-group negotiations, case-based clinical scenarios, personal reflection, and facilitated debrief. The tools are customizable based on audience and available instructional time. Results: We implemented this resource for over 2 years with 20 pediatric residents and over 150 educators and fellows at national meetings. Participants reported that the topic was timely and important and identified the conflict resolution hierarchy, attention to conflict resolution styles, use of case-based discussion, and focus on nonverbal communication as effective and valuable elements. Discussion: This resource has been refined over five cycles of presentation and feedback with learners and educators. Our participants identified themes of conflicts in clinical settings that informed the case scenarios presented here, including interdisciplinary conflicts, ethical conflicts, and conflicts among members of the educational hierarchy. These tools are designed to meet established national educational priorities related to communication and professionalism across the educational continuum.

Bad News Deserves Better Communication: A Customizable Curriculum for Teaching Learners to Share Life-Altering Information in Pediatrics.

INTRODUCTION: Learners have repeatedly expressed a desire for more structured training in communicating with families, especially when sharing life-altering information and breaking bad news. Concurrently, parents have indicated that pediatricians could conduct difficult conversations with greater skill. Based on local needs assessments and available pediatric literature, this guide presents didactic materials and a workshop-style, case-based, longitudinal approach for teaching communication skills to learners in pediatrics. METHODS: The customizable guide can be implemented as a 1-hour didactic presentation, a 1- to 3-hour workshop, or an integrated longitudinal curriculum. Unlike other available resources for breaking bad news, this guide is specifically designed for pediatrics and uses evidence-based communication guidelines developed for pediatric settings. The guidelines are modified from the adult-centered SPIKES (setting, perception, involvement, knowledge, emotions, summary) approach. The material was created by clinicians, educators, and parents of pediatric patients. In addition to video-based didactic materials and pediatric case scenarios, the guide includes materials for assessment, evaluation, and personal reflection. RESULTS: The modified SPIKES approach and didactic portion of this resource were validated as an initial training tool, yielding significant improvements in self-efficacy of pediatric providers and learners. Evaluations of the role-playing components provided by pediatric residents and fellows have been positive for the format and value of the learning experience. Participants reported a particular benefit from the inclusion of parent perspectives. DISCUSSION: Without a formal communication curriculum, learners must rely on chance observation of life-altering conversations during clinical rotations. This guide provides pediatric educators with structured, evidence-based materials to teach advanced communication skills.

Effects of experimental anemia on blood ion and acid-base status of turtles during submergence in aerated water at 3 degrees C.

The importance of blood hemoglobin to aquatic oxygen uptake by turtles (Chrysemys picta bellii) submerged in aerated water at 3 degrees C was tested by comparing the responses of anemic turtles (hematocrit approximately 6%) to turtles with normal hematocrits (hematocrit approximately 33%). All turtles were submerged for 42 days and blood samples were collected at 0, 7, 21, 32 and 42 days. Blood was analyzed for pH, PCO(2), PO(2), hematocrit, hemoglobin concentration ([Hb]) and plasma was analyzed for concentrations of lactate, glucose, Na(+), K(+), Ca(2+) and Mg(2+). Plasma [HCO(3)(-)] was calculated. [Hb] correlated closely with hematocrit levels. [Lactate] reached higher final values in anemic turtles (34.5+/-5.3 mmol l(-1)) than in normal turtles (14.5+/-4.6 mmol l(-1)) indicating a greater reliance of the anemic animals on anaerobic metabolism. Both groups compensated for acidosis by reduced PCO(2) and anemic turtles also had increased [Ca(2+)] and [Mg(2+)]. Blood pH fell significantly in the anemic turtles but not in the controls. Although the data indicate that the anemic turtles relied more on anaerobic metabolism than the controls, the effect was much less than expected on the basis of the reduced blood O(2) carrying capacity. Possible compensatory mechanisms utilized by the anemic turtles to minimize anaerobic metabolism are discussed.