Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study.

OBJECTIVE: Despite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, such curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key curricular elements for educating NPM fellows, advanced practice providers, and attending physicians in the critical topics of IB and health disparities. STUDY DESIGN: A modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit. RESULT: Three Delphi rounds were conducted from May to November 2021. Experts reached consensus on a variety of items for inclusion in the curriculum, including educational goals, learning objectives, teaching strategies, and educator principles. CONCLUSION: Essential curricular components of an IB and health disparities curriculum for neonatal medicine were defined using rigorous consensus building methodology.

Flipping the Teachers: Impact of a Standardized Physiology Curriculum on Neonatology Medical Educators.

OBJECTIVE: Academic physicians must teach elements in an Accreditation Council for Graduate Medical Education (ACGME)-mandated curriculum while balancing career development and clinical workload. Exploring educator perceptions on the learning environment and comparing two instructional methods (traditional didactics [TD] vs. flipped classroom [FC]) in one pediatric subspecialty may elucidate current challenges, barriers, and strategies to optimize learning and educator satisfaction. STUDY DESIGN: A randomized trial comparing effectiveness and learner preference for FC versus TD physiology teaching was conducted in ACGME-accredited neonatal-perinatal medicine (NPM) fellowship programs in 2018 to 2019. Educator preferences were elicited through online surveys pre- and postintervention. Free-text comments were provided for questions exploring strengths, challenges, and opportunities in fellowship education. Statistical analysis included comparisons of demographics and pre-post-intervention educator responses between groups. Thematic analysis of text responses was conducted to identify common subthemes. RESULTS: From 61 participating programs, 114 FC educators and 130 TD educators completed surveys. At baseline, all educators experienced professional satisfaction from teaching fellows, but noted challenges with time available to create and/or deliver educational content, limited content expertise amongst faculty, colleagues' limited enthusiasm toward educating fellows, and lack of perceived value of education by institutions given limited protected time or credit toward promotion. Postintervention, educators in both groups noted a preference to teach physiology using FC due to interactivity, learner enthusiasm, and learner-centeredness. FC educators had a 17% increase in preference to teach using FC (p = 0.001). Challenges with FC included ensuring adequate trainee preparation, protecting educational time, and providing educators with opportunities to develop facilitation skills. CONCLUSION: Overall, NPM educators in a trial evaluating a standardized, peer-reviewed curriculum report professional satisfaction from teaching, but described logistical challenges with developing/delivering content. Educators preferred instruction using FC, but identified challenges with learner preparedness and ensuring adequate educator time and skill. Future efforts should be dedicated to addressing these barriers. KEY POINTS: · Many challenges exist for educators teaching neonatal-perinatal medicine fellows, including time, support, and recognition.. · Many educators preferred using flipped classroom methodology with a standardized curriculum due to interactivity and learner-centeredness.. · Benefits of a standardized, peer-reviewed curriculum include reduced preparation time, adaptability of content, and learning environment enhancement..

Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial.

OBJECTIVE: Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN: Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS: 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS: FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.

Changes, Challenges, and Variations in Neonatal-Perinatal Medicine Fellowship: A View from the Program Directors.

OBJECTIVE: Neonatal-perinatal medicine (NPM) fellowship programs in the United States support >800 learners annually. Understanding variations in the programmatic structure, challenges, and needs is essential to optimize the educational environment and ensure the specialty's future. STUDY DESIGN: NPM fellowship program directors (PDs) and associate program directors (APDs) were invited to complete an electronic survey on their program administration, recruitment, clinical training, assessment methods, scholarly program, and career pathways. Each participant identified individual programmatic strengths, challenges, opportunities, and threats to the field. RESULTS: Representatives from 59 NPM fellowships provided data (response rate 59/96 = 61%). In total, 30% of PDs received less than the Accreditation Council for Graduate Medical Education -recommended protected time for administrative duties, and 44% of APDs received no protected time. Fellow clinical service assignments varied widely from 13 to 18 months and 90 to 175 call nights over 3 years. Recruitment practices varied across programs; 59% of respondents raised concerns over the pipeline of applicants. Conflicts between fellows and advanced practice providers were identified by 61% of responders. Programs varied in their scholarly offerings, with 44% of NPM fellowships interested in adding broader research opportunities. CONCLUSIONS: NPM fellowship leaders identified a need for improved programmatic support, enhanced measures to assess competency, opportunities to strengthen scholarly programs, shared curricular resources, and strategies to balance education with clinical demands. PDs and APDs identified threats to the future of NPM training programs including the diminishing pipeline of applicants into neonatology, challenges with clinical exposure and competence, inadequate support for the educational mission, issues supporting high-quality scholarship, and fewer graduates pursuing physician-investigator pathways. National organizations and academic institutions should take action to address these challenges so that fellowships can optimally prepare graduates to meet their patients' needs. KEY POINTS: · Numerous challenges exist for current program directors in NPM including balancing clinical work with scholarly activities, accurately assessing competency, optimizing the culture of the learning environment, and ensuring that fellows are adequately prepared for a range of postgraduate positions.. · Significant variation exists across NPM fellowship programs in clinical service/calls assigned over 3 years of fellowship training, as well as opportunities to pursue scholarly activities across a variety of areas.. · Challenges exist related to ensuring an adequate number of future applicants into the specialty, including those from backgrounds traditionally underrepresented in medicine, as well as those seeking to pursue careers as physician-investigators..

Part 5: Essentials of Neonatal-Perinatal Medicine Fellowship: evaluation of competence and proficiency using Milestones.

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Milestone Level Changes From Residency to Fellowship: A Multicenter Cohort Study.

BACKGROUND: A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. OBJECTIVE: Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. METHODS: We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. RESULTS: A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). CONCLUSIONS: Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.

Value, Strengths, and Challenges of e-Learning Modules Paired with the Flipped Classroom for Graduate Medical Education: A Survey from the National Neonatology Curriculum.

OBJECTIVE: This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. STUDY DESIGN: This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. RESULTS: Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30-60 vs. 0-15 minutes, p < 0.01). Faculty facilitators reported less preparation time before facilitating a FC compared with the time required for creating a new didactic lecture (median: 60 vs. 240 minutes, p < 0.01). Both fellows and faculty respondents preferred the FC approach to traditional didactics, with fellows showing a greater degree of preference than faculty (68 vs. 52%, respectively, p = 0.04). CONCLUSION: Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

Development and Validation of a Theory-Informed Group Learning Environment Assessment Tool for Graduate Medical Education Programs.

BACKGROUND: Recent studies showed that psychological safety is important to resident perception of the work environment, and improved psychological safety improves resident satisfaction survey scores. However, there is no evidence in medical education literature specifically addressing relationships between psychological safety and learning behaviors or its impact on learning outcomes. OBJECTIVE: We developed and gathered validity evidence for a group learning environment assessment tool using Edmondson's Teaming Theory and Webb's Depth of Knowledge model as a theoretical framework. METHODS: In 2018, investigators developed the preliminary tool. The authors administered the resulting survey to neonatology faculty and trainees at Baylor College of Medicine morning report sessions and collected validity evidence (content, response process, and internal structure) to describe the instrument's psychometric properties. RESULTS: Between December 2018 and July 2019, 450 surveys were administered, and 393 completed surveys were collected (87% response rate). Exploratory factor analysis and confirmatory factor analysis testing the 3-factor measurement model of the 15-item tool showed acceptable fit of the hypothesized model with standardized root mean square residual = 0.034, root mean square error approximation = 0.088, and comparative fit index = 0.987. Standardized path coefficients ranged from 0.66 to 0.97. Almost all absolute standardized residual correlations were less than 0.10. Cronbach's alpha scores showed internal consistency of the constructs. There was a high correlation among the constructs. CONCLUSIONS: Validity evidence suggests the developed group learning assessment tool is a reliable instrument to assess psychological safety, learning behaviors, and learning outcomes during group learning sessions such as morning report.

Pediatric Residency Graduates Preparedness for Neonatal-Perinatal Medicine Fellowship: The Perspective of First-Year Fellows.

OBJECTIVE: This study aimed to report on Neonatal-Perinatal Medicine (NPM) fellows' views of self-preparedness upon starting postresidency training. STUDY DESIGN: We conducted a national survey of first-year NPM fellows in the United States. The validated survey had five major areas: professionalism, psychomotor ability, independence/graduated responsibility, clinical evaluation, and academia. Survey responses were analyzed using descriptive statistics, and the free-text answers were categorized. RESULTS: Of 228 potential first-year NPM fellows, 140 (61%) initially responded to the survey. Overall, the fellows perceived themselves positively in professionalism and independence/graduated responsibility domains. Marked variability was observed in perceived preparedness in psychomotor ability, with confidence in neonatal intubation and arterial line placement of 86 and 49%, respectively. Lack of confidence in performing neonatal intubation procedures correlates with lack of attempts. The majority (75%) of fellows reported being interested in academia, but less than half felt capable of writing an article. CONCLUSION: First-year NPM fellows identified deficiencies in the domains of psychomotor ability and academia. Residency and fellowship programs should partner to address these deficiencies.

A novel approach using volumetric dynamic airway computed tomography to determine positive end-expiratory pressure (PEEP) settings to maintain airway patency in ventilated infants with bronchopulmonary dysplasia.

BACKGROUND: Positive end-expiratory pressure (PEEP) is a key mechanical ventilator setting in infants with bronchopulmonary dysplasia (BPD). Excessive PEEP can result in insufficient carbon dioxide elimination and lung damage, while insufficient PEEP can result in impaired gas exchange secondary to airway and alveolar collapse. Determining PEEP settings based on clinical parameters alone is challenging and variable. OBJECTIVE: The purpose of this study was to describe our experience using dynamic airway CT to determine the lowest PEEP setting sufficient to maintain expiratory central airway patency of at least 50% of the inspiratory cross-sectional area in children with BPD requiring long-term ventilator support. MATERIALS AND METHODS: We retrospectively identified all infants with BPD who underwent volumetric CT with a dynamic airway protocol for PEEP optimization from December 2014 through April 2019. Sixteen infants with BPD underwent 17 CT exams. Each CT exam consisted of acquisitions spanning the trachea and mainstem bronchi. We measured cross-sectional area of the trachea and mainstem bronchi and qualitatively assessed the amount of atelectasis. We documented changes in management as a result of the CT exam. RESULTS: The average effective dose was 0.1-0.8 mSv/scan. Of 17 CT exams, PEEP was increased in 9, decreased in 3 and unchanged after 5 exams. CONCLUSION: Dynamic airway CT shows promise to assist the clinician in determining PEEP settings to maintain airway patency in infants with BPD requiring long-term ventilator support. Further evaluation of the impact of this maneuver on gas exchange, cardiac output and other physiological measures is needed.

Focused Evidence-Based Medicine Curriculum for Trainees in Neonatal-Perinatal Medicine.

Introduction: While evidence-based medicine (EBM) is an Accreditation Council for Graduate Medical Education core competency, EBM teaching in pediatric subspecialties is rarely reported. Therefore, we designed, implemented, and evaluated this focused EBM curriculum for trainees in neonatal-perinatal medicine. Methods: This EBM curriculum consists of seven weekly 1-hour sessions. Specific EBM skills taught in the sessions include formulating a structured clinical question, conducting an efficient literature search, critically appraising published literature in both intervention and diagnostic studies, and incorporating evidence into clinical decision-making. The course was evaluated by a neonatology-adapted Fresno test (NAFT) and neonatology case vignettes, which were administered to learners before and after the curriculum. This publication includes the needs assessment survey, PowerPoint slides for the seven sessions, the NAFT, and the scoring rubric for the test. Results: The NAFT was internally reliable, with a Cronbach's alpha of .74. The intraclass correlation coefficient of the three raters' variability in assessment of learners was excellent at .98. Mean test scores increased significantly (54 points, p < .001) in 14 learners after the EBM curriculum, indicating an increase in EBM-related knowledge and skills. Discussion: This focused EBM curriculum enhances trainees' knowledge and skills and fosters evidence-based practice. The curriculum can be easily adapted for learners in pediatrics, as well as family medicine, in order to enhance trainees' EBM skills and knowledge.