Evaluation of the Current Critical Care Medicine Rotation Curriculum at Duke University’s
Internal Medicine Residency Training Program
Background and Significance
The intensive care unit (ICU) is a complex and dynamic environment. It has many challenges for its health care providers. Despite literature that indicates care offered by subspecialists trained in critical care medicine (CCM) improves patient outcomes at a lesser cost, most ICUs in the United States are staffed by non-CCM–board certified physicians. The current situation is likely to persist or increase due to the projected shortage in the number of intensivists over the next two decades 1. Because many of these non–critical care trained providers are internists, CCM training is becoming more and more a priority for many internal medicine residency programs 2. This indicates a need to incorporate an effective training of medical residents to manage critically ill patients.
Despite this growing need, the education of residents in CCM is challenging 2. The unpredictability of patients’ illnesses and the schedule of the day in ICUs, residents’ duty hour restrictions, and focus on patient safety and quality of care are some factors that may compromise this achievement 3. These stresses on the current graduate medical education curriculum may generate conflicts between providing optimal patient care and resident education 3. Therefore, studying the current status of critical care education during internal medicine residency training program is necessary to have a better understanding before designing changes and implementing them.
Literature indicates the absence of well-formed and standardized ICU curriculum that is established among various training programs of internal medicine4. It would be needed to identify current teaching practices, resources, and environments. Many studies have reported suboptimal training of residents in some CCM practices and topics, such as mechanical ventilation and variation in the amount of efforts devoted to education in acute illness 3,5. In addition, methods for teaching residents in the ICU have changed since the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour standards to applied, competencies to be met and lately milestones to be developed 6,7,8.
Problem Statement
Medical residents have their Medical ICU (MICU) rotation during their second year of residency training at Duke University. It is a complex clinical rotation during that academic year, as they need to acquire variable learning domains with physical exhaustion. Medical residents and the faculty had concerns about the need to improve the current MICU curriculum at our institution. Residents perceive their rotation as it is meant to provide clinical service, without a remarkable improvement in their knowledge, attitude and skills required to manage critically ill patients. Faculty members raised a concern of suboptimal performance, as residents start their MICU rotation as third year. All concerns from residents and faculty are not studied before in review of literature.
This research is to determine the deficiencies and barriers of the current MICU curriculum for second year medical residents rotation that faculty and residents address to prevent having a learning environment, and activities need to be considered in the MICU curriculum at Duke University.
Research Questions:
What are the learning domains deficiencies in the current MICU curriculum for second year medical residents when they have their MICU rotation at Duke University Hospital?
What are the required educational activities that need to be considered during the MICU rotation for second year internal medicine residents at Duke University Hospital?
What are the barriers to implement changes and transformation of the MICU curriculum, to include necessary activities?
Design:
We plan to study subjectively the level of satisfaction and learning gained by medical residents after the end of their rotation. This study will have the subjective evaluation of both; medical residents and faculty members about the current Medical Intensive Care Unit (MICU) rotation curriculum. The study will be questionnaire-based with closed and open-ended responses that will allow quantitative and qualitative analyses respectively. An institutional Review Board (IRB) will be obtained ad is being processed. Survey questionnaires will be developed, validated among a small group of residents and faculty then distributed among the subjects.
Overall, it is going to be a mixed method research that has surveys with closed ended questions to be analyzed quantitatively, and focus groups to be analyzed Qualitatively of both; faculty and residents.
Sampling
Subjects of this study will be medical residents and faculty rounding attendings. Medical residents who complete their MICU rotation will receive an email to be enrolled in the study. It will substitute their feedback about the rotation that is required by the training program. Residents agreed will be consented for this study. Rounding faculty members at the MICU will receive an invitation to be enrolled; those accepting will be consented as well.
Second year medical residents whom will be enrolled are the learners’ group during this rotation. They represent a homogenous and typical sample hence they are the target population to benefit from the curriculum. The rounding faculty members are the tutors (instructors) of the rotation. They are not as homogenous (rather heterogeneous) as the level of experience and teaching skills are variable among them. However, they all share rounding and guidance to medical residents during the rotation.
Survey Questionnaire:
The survey will be structured and adapted from the national survey among residency training programs 4 and will be modified using the work published by Artino et al 9. It will address their evaluation and satisfaction about the current curriculum by faculty members and residents.
The MICU curriculum has three target learning domains for medical residents. These include; knowledge, attitude and skills gained. The knowledge domain consists mainly of a number critical care topics and illnesses that need to be understood. The skills to be practiced are procedures and interactions and management of critically ill patient. Those two domains will be subjectively evaluated through closed-ended questions that will subjectively address the level of satisfaction of both groups. The attitude domain is focused on interactions between family and the caring medical team, medical providers and their satisfaction on provision of care and discussion of end-of-life care if indicated for critically ill patients.
The survey will be designed with closed-ended questions that should reflect knowledge and skills learning domains. The attitude domain will be reviewed using assays (open-ended response) that should represent satisfaction and barriers of both groups about this learning domain. They will be distributed among a small number of faculty members and residents for validation. Below are examples of the survey questions.
Data Collection:
The MICU curriculum committee at Duke University Hospital (researchers) will meet after survey questionnaires are answered by the subjects of faculty and residents, whom have completed the survey.
Quantitative Analysis will take place for closed ended answers by both groups. Deficiencies in learning domains will be determined through calculation of means or medians and standard deviations to determine significance. This will be further discussed with a biostatistician.
Focus groups will be generated by the researchers through reading the short assay completed by the subjects of both groups. Further analysis will be carried over after clustering them. After generation of focus groups, a qualitative document analysis will be performed on the assays of students by the principle investigator (myself). This is to eliminate bias and unify determination of the assays. The sample survey analysis should help to eradicate errors of understanding by the researchers as well through the review after that phase.
Correlation analysis of the answers among faculty and medical residents will be considered to find concordance and discordance. These findings will allow the researchers to identify deficiencies that will be the foundation to transform the current MICU curriculum to an updated one that incorporates milestones implementation and great areas of the current curriculum and how to build the current curriculum.
Implementation
Being in an academic institution with great academic and training performance, the concept of transformation of current curricula may require a number of meetings to occur. Some of these meetings have occurred. Others are to occur in the near future. This may explain the timeline I anticipate below to avoid over ambition.
The Curriculum committee will meet to discuss the undocumented satisfaction and the literature behind the need to study the current curriculum satisfaction from medical residents and faculty views. The development of the survey questionnaires will need around 4-6 weeks; so all members of the committee (researchers) reach an agreement. The IRB approval will need 2-4 weeks. The pilot distribution among few of both groups to determine clarity and understanding will require about 2 weeks. Two further weeks will be needed for corrections.
Distribution of the surveys will take place after each rotation in one academic year of training, to have almost all medical residents involved. Data analysis and results will approximately require 4 weeks, as estimated from other projects within the institution. Bio-statistical support will need that duration for analysis
Reflection
This course has enlightened me with research methods and types in medical education. I was keeping in mind the quantitative options only for research in general. Thoughts about sharing innovations and thoughts is by itself valuable research. It does not have to be a clinical trial with quantitative measurable outcomes all the time!
Qualitative and quantitative methods are different. both have their own strengths and assumptions. Some questions well-suited to qualitative research are open-ended and exploratory for me such as: How do residents experience end-of-life discussions in the ICUs? what do they gain from these discussions? or What do learners find most valuable in their rotation?
The qualitative research process is iterative, which means that the analysis may inform additional sampling and data collection, leading to further analysis and interpretation. The process may be best conceived as a spiral in which data is the input and an integrated narrative account is the output, incorporating multiple cycles of data collection and analysis. Various techniques exist to establish trustworthiness in qualitative data analysis, including using multiple coders, having external peers review the themes or coding, allowing participants to give feedback on the emerging themes and interpretations. All this information has been taught to me through this wonderful course. I wish to achieve the end of this proposal to gain the benefit of application of mixed research methods in medical education.
References
Halpern NA, Pastores SM, Oropello JM, Kvetan V. Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty. Crit. Care Med. 2013;41(12):2754-2761.
Croley WC, Rothenberg DM. Education of trainees in the intensive care unit. Crit. Care Med. 2007;35(2 Suppl):S117-121.
Chudgar SM, Cox CE, Que LG, Andolsek K, Knudsen NW, Clay AS. Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? Crit. Care Med. 2009;37(1):49-60.
Almoosa KF, Goldenhar LM, Puchalski J, Ying J, Panos RJ. Critical Care Education During Internal Medicine Residency: A National Survey. J. Grad. Med. Educ. 2010;2(4):555-561.
Cox CE, Carson SS, Ely EW, et al. Effectiveness of medical resident education in mechanical ventilation. Am. J. Respir. Crit. Care Med. 2003;167(1):32-38.
Nabors C, Peterson SJ, Forman L, et al. Operationalizing the internal medicine milestones-an early status report. J. Grad. Med. Educ. 2013;5(1):130-137.
Shoeb M, Khanna R, Fang M, et al. Internal medicine rounding practices and the Accreditation Council for Graduate Medical Education core competencies. J. Hosp. Med. 2014;9(4):239-243.
Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J. Grad. Med. Educ. 2009;1(1):5-20.
Artino AR, Jr., La Rochelle JS, Dezee KJ, Gehlbach H. Developing questionnaires for educational research: AMEE Guide No. 87. Med. Teach. 2014;36(6):463-474.
Updated @July 2015