A Pediatric Residency Research Curriculum

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Until relatively recently, the overriding purpose of residency training in any specialty or subspecialty was to train medical experts to provide competent patient care. In 1996, the Royal College of Physicians and Surgeons of Canada (RCPSC) defined 7 competencies for specialists (the CanMEDS framework): medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. In 2001, the American Board of Pediatrics (ABP) recognized 6 general pediatric competencies: patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice. In both of these models, the central competencies are related to patient care, with an emphasis on the importance of basic skills in a critical appraisal of the literature required to provide evidence-based care. The RCPSC, within the scholar competency, requires that physicians “demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.” In recognition of the importance of research in the ongoing care of children, the American Academy of Pediatrics (AAP) Committee on Pediatric Research recommends that every training program provide a research curriculum for all pediatric residents, to “equip pediatric residents with the skills necessary to evaluate and use medical literature competently and…equip the resident with a basic knowledge of scientific methods, research design fundamentals, core statistical principles, and the means to conduct literature reviews.”¹ Heavier clinical demands, ever-increasing child health and science knowledge bases, and more humane working hours have made incorporation of these non–medical expert educational objectives into residency programs challenging. We describe a 1-month rotation specifically designed to address these objectives that we recently incorporated into our pediatric resident training program.

In 2003, our residency program initiated a course to teach research skills to first-year residents. Due to a change in how the university's postgraduate medical education office scheduled vacations, we needed an extra 4-week rotation for these residents. Previously, first-year residents were required to take their vacation in a 4-week block. In 2003, the policy changed, allowing residents could take vacation in 1- or 2-week blocks throughout the year. Our Residency Training Committee (RTC) made the decision to use this new rotation to develop an academic skills course that focused on the other CanMEDS competencies besides medical expert. The course was initially developed to increase residents' competence in critical appraisal and research skills, a key competence of the scholar role. Previously, we had conducted sessions on critical appraisal every 2 years as part of the academic half-day curriculum (in which residents attend a weekly 4-hour academic session consisting of didactic lectures, seminars, and journal clubs). When these sessions were first implemented, it was a new area, and the skills were not taught as part of the medical undergraduate curriculum. By 2003, however, graduates of Canadian medical schools routinely received teaching in critical appraisal; thus, the course was clearly outdated and required renewal. Our RTC felt that we still needed to teach critical appraisal, because residents from other countries may not receive this training in their undergraduate medical education. We also were concerned that our residents' research experience and activity was not yet adequate and could be enhanced. Consequently, we undertook a revision of our programmatic curriculum in the scholar competency, including research knowledge and skills, resulting in the academic skills course described herein.

Although we felt strongly that residents should be involved in independent research projects, this was not a mandatory component of our program. Some residents had a strong research background before entering the program and successfully completed research projects during residency, whereas others had no interest in pursuing research projects and rarely became involved in any research during residency. Our focus in course development was on those residents with little or no research background but an interest in doing research. At the time, such residents often did not successfully complete their research projects. Reasons for noncompletion included an inappropriate study (either too large or with insufficient available resources), the wrong research question, the wrong data, inappropriate data entry, improper study design, inability to pass the Research Ethics Board (REB) review, inability to obtain a grant, and, even insufficient time. With only 3 years to finish the project, far too many residents were unable to complete their projects. We decided to use our “extra” 4-week rotation to teach residents how to design a realistic project that could be completed in the available time frame. Along with teaching research design and critical appraisal, we also aimed to address other non–medical expert CanMEDS competencies. Another important aspect of the scholar role is the ability to teach, including children, families, colleagues, junior trainees, and other health professionals. We elected to use 1 of the weeks for “teaching teaching.” Our rather grandly named “academic skills course” is mandatory for all first-year residents.

The RTC recognized that first-year residents are very busy and often feel overwhelmed by the amount they must learn and experience stress while making the transition from student to physician. We wanted the course to be enjoyable as well as educational for the residents; consequently, we decided to schedule it early enough in the academic year to give the residents time to organize their research projects to start in their second year; but also late enough in the academic year so that they would be able to concentrate on the course without feeling stress about not being on a clinical rotation. (First-year residents tend to focus their learning primarily in the medical expert role.) Thus, we scheduled the course for mid-January to mid-February. All first-year residents take the course at the same time; it is their “rotation” for that month. Because previously each resident would have been off at some point during the year for his or her 4-week vacation, our program was structured for each first-year resident to complete only 12 4-week rotations. This is the resident's 13th rotation, and thus he or she has no daytime clinical duties. Call is reduced, usually to only 1 Friday and 1 Saturday during the rotation, ensuring no post-call days to compromise attendance. The residents attend their weekly academic half-day during the course, with at least 1 of the half-days incorporated into the academic skills course. Each year a new topic is introduced, and that session is offered to all of the residents in the program during half-day, allowing all residents (including those who took the course in previous years) to benefit from new additions to the course. The 4-week curriculum of the academic skills course is outlined in the Table (available at www.jpeds.com).

Table.

First jump: A clinical scenario is presented, for example: “A teenage male with asthma is readmitted to your service. He realizes that cigarette smoking may be contributing to his poor asthma control. He asks you if ‘the patch’ might help him stop smoking.” The resident must identify the clinical question, state what he or she thinks the answer will be, and outline 3 sources of information that he or she will use to confirm the answer. Sources may include electronic databases, clinical guidelines, or local experts in the field.

Second jump: The resident has 30 minutes to search for evidence to answer the clinical question.

Third jump: The resident must outline how he or she will explain the evidence to the patient to answer his or her question.

* Triple jump. This is an exercise in evidence gathering. A resident is assigned a clinical problem and has 30 minutes to find the evidence to support his or her answer. The time frame is kept deliberately short to simulate typical clinical practice.

The first 2 weeks of the course involves didactic sessions on basic research topics, such as literature searches, critical appraisal, research question development, study design, statistics, and the function of ethics review boards. During these 2 weeks, the residents perform and submit a critically appraised topic. The residents have unscheduled time to develop a research question and a research proposal to address that question. Keeping in mind the possible barriers to completing research listed earlier, the third-week residents present and discuss their research proposals with the group. This allows every resident to benefit from the discussion of each project. Initially, each resident presents his or her proposal to the core faculty involved in the course, to ensure that the proposed project is of a reasonable size and complexity to allow completion during training. Next, the resident presents the proposal to 2 faculty members involved in full-time research, who evaluate whether the planned study design will answer the question being asked and also whether the planned data gathering and statistical analysis methods are appropriate. Finally, the resident presents the proposal to members of the REB, allowing discussion of ethical issues and suggestions for preparing the proposal for REB submission.

The final week of the course is focused primarily on developing teaching skills. In the first 2 years of the course, our Faculty of Medicine's Division of Medical Education presented this part of the curriculum. But the residents felt that these nonclinician educators did not understand the unique nature of resident teaching, and that much of the information was not relevant; therefore, we switched to pediatrician educators. Subsequent resident evaluations indicate that the teaching is more relevant when done by pediatricians who understand the resident's role in teaching more junior trainees.

Each year the residents evaluate each session, including the topic and the faculty speaker. We use a weekly anonymous written evaluation completed by each resident, as well as face-to-face feedback from the entire resident group with the program director at the course's midpoint and end. The course has changed, and improved, annually in response to these evaluations and feedback. Since the course was introduced, all residents are actively involved in research projects, and there has been a substantial increase in the successful completion of resident research projects. As of July 2007, completion of a scholarly project is a mandatory component of our program.

Although we had the opportunity to condense this curriculum into a 4-week course, the sessions also could be presented longitudinally during academic half-days. It is likely, however, that the more intense and focused delivery of the curriculum during a single 4-week rotation enhances the course's effectiveness and allows residents to be less distracted by clinical duties and related educational demands. The curriculum provides the resident with at least a basic appreciation of the continuum of pediatric research and has resulted in a marked increase in the number of successful research projects completed by our pediatric residents. We feel that this curriculum meets the standards set by the ABP and the RCPSC. It also meets, and sometimes even exceeds, the recommendations of the AAP's Committee on Pediatric Research.

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Reference 

1. American Academy of Pediatrics Committee on Pediatric Research. Promoting education, mentorship, and support for pediatric research. Pediatrics. 2001;107:1447–1450
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