Chapter 17 Educating the Intensivist
Pediatric critical care medicine is a discipline dedicated to the care of the critically ill child. It focuses on the sick child as a whole and takes into account the impact of disease on all organ systems, addressing the physical, mental, and emotional needs of the child and those of his or her family as well. The education and training of pediatric intensivists are focused on patient care principles that include resuscitation, advanced life support, management of traumatic injury, postoperative care, application of all modes of mechanical ventilation, renal replacement therapy, cardiovascular support, hemodynamic and neurologic monitoring; management of poisonings, pulmonary, hematologic/oncologic, and metabolic disorders; pharmacologic principles; transplantation; procedural sedation; and infectious diseases. However, the complex needs of the critically ill child also require that intensivists be prepared to assume a leadership role in the coordination of this care among persons from multiple disciplines who are part of the team. In addition, the pediatric intensivist has to develop an understanding of the ethics of critical care medicine and be able to balance complex and high technology care with humanistic principles and respect for the patient as a human being. The intensivist must also develop skills for evaluating medical literature that reports clinical and/or basic science research and develop the ability to teach learners of different levels effectively.
The required elements for the education and training of pediatric intensivists in patient care have been defined over time and continue to evolve (see Chapter 1 for the history of the specialty). The American Board of Pediatrics (ABP) has developed a list of content specifications for the subspecialty examination. While this list is not intended to serve as a curriculum, the pediatric intensivist sitting for the examination is expected to be familiar with more than 2000 items listed on 169 pages. The Pediatric Critical Care Medicine Content Outline has 16 sections that include the following: cardiovascular, respiratory, neurology and neuromuscular, infectious disease, immunology and inflammation, renal and electrolytes, metabolism and endocrinology, hematology/oncology, gastroenterology/nutrition, poisonings, toxins and overdoses, trauma and burns, pharmacology, anesthesiology and postoperative care, technical procedures, principles of monitoring, special critical care issues, and core knowledge in scholarly activities. To qualify for the ABP subspecialty examination, applicants are required to have certification in general pediatrics, to have completed training in critical care medicine in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME), and to provide evidence of meaningful research during training.
Pediatric critical care medicine is one of the accredited subspecialties of the ACGME. As such, oversight for the training programs is provided by the Pediatric Review Committee. In addition to meaningful scholarship by faculty members and trainees, requirements for program accreditation include faculty credentials such as subspecialty board certification, an active role in the training program, and research productivity and funding. Fellowship training requirements include but are not limited to defined patient numbers and adequate opportunity to develop procedural competence, a didactic curriculum that is comprehensive and is regularly implemented, formal education related to developing teaching skills, and evaluation of competency. These requirements are evaluated by the Pediatric Review Committee according to six competencies, as outlined at the following Web site: www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf.
In 1999, the ACGME initiated an outcome project to design a conceptual framework for education and training according to six common program requirements or general competencies.1 The objective of the outcome project was to “ensure and improve the quality of graduate medical education.”2 The ACGME recommends that trainees demonstrate the following:
While many persons remember fellowship training that involved 16-hour days, being on call every other night, and working on research projects on weekends off, new regulations have led to major changes in fellowship training schedules. In the United States, duty hours are now limited and may be further shortened.4 The duty-hour restrictions are based on studies suggesting that sleep deprivation causes significant decrements in physician performance in the areas of neurocognition and clinical tasks that result in medical and surgical errors. On July 1, 2003, the ACGME implemented duty-hour regulations for all ACGME-accredited programs. These regulations included limitation of total average work hours to 80 hours per week; limitation of the length of an individual shift to 24 hours plus 6 hours for task completion and handover; the requirement of at least 10 hours off between shifts; and the requirement of at least 4 days off over a 4-week period. More recently, the Institute of Medicine has suggested further shortening of duty hours.4 Historically the limitation of duty hours is related to the Libby Zion case5 and the findings of the Bell Commission in New York.6 Whereas the death of Libby Zion was attributed to the physician trainees’ long work hours, the Bell Commission findings indicate that the evidence was not convincing in this regard. Rather, this Commission believed that her death was more likely related to knowledge deficit and lack of supervision of trainees.
While few other issues in medicine have generated emotional discussions of such magnitude within the medical community in the United States, work-hour restrictions have long been in place in Canada, France, and other European nations. Since the implementation of duty-hour restrictions, a number of studies have evaluated the effects of this mandate on patient care. Landrigan et al.7 studied the effect of work hours on serious medical errors in the intensive care unit (ICU) comparing a traditional work shift of 24 hours or more with every third night on call and an “intervention” schedule that eliminated extended work shifts and reduced work hours each week. The interns made 35.9% more serious medication errors while working under the traditional schedule. In addition, the interns made 5.6 times as many serious diagnostic errors while working a traditional work shift. However, in a more recent study, the same group evaluated the effects of the ACGME duty-hour limits on sleep, work hours, and safety in a group of 220 residents8 and found no changes in the total numbers of work and sleep hours. More importantly, rates of medication errors, resident depression, and resident injuries did not decrease, and educational ratings did not improve. Volpp et al.9 studied the effects of duty-hour restriction on the mortality rate of hospitalized Medicare beneficiaries9 and found no worsening or improvement. On the other hand, Prasad et al.10 conducted a retrospective cohort study comparing ICU mortality in teaching and nonteaching hospitals before and after implementation of duty-hour regulations and found that there was a decrease in in-hospital mortality rates among ICU patients following the implementation of duty-hour restrictions regardless of teaching or nonteaching hospital status.
Meanwhile, the amount of information and number of skills that have to be acquired and mastered by pediatric intensivists continue to increase. In spite of this situation, Chudgar et al.11 showed that medical education and teaching methods in the ICU have not changed since the implementation of the ACGME duty hour restrictions. In addition, the program directors who were surveyed were concerned that the new restrictions have negatively affected resident attitudes, continuity of care, and their availability for educational activities. Kairys et al.12 showed that there has been a decline in the total operative cases reported by graduating surgical residents. In addition to the potential to reduce clinical skills and fracture continuity of care, the plan to further reduce duty hours has generated other concerns. As the work hours of trainees are shortened, patient care tasks have fallen on attending physicians who do not have work-hour limits. This group of physicians tends to be older and they have many other responsibilities that include research, teaching, and administration. Mercurio and Peterec13 aptly describe this dilemma in their 2009 article in Pediatrics, “Attending Physician Work Hours: Ethical Considerations and the Last Doctor Standing.” Other concerns include the lack of continuity of physician-patient interactions. Charap14 writes: “Reducing work hours limits the numbers of patients that residents care for and the extent of residents’ involvement with individual patients. By limiting the diversity, intensity, and continuity of physician-patient interactions, our residents will probably have gaps in their clinical skills. These skills are not reflected in in-service or board certification examinations. They deal with recognizing patterns and discerning the very sick patients from the not-so-sick patients.”14
Regardless of where the road of duty hours takes us, we have to develop novel ways of teaching to ensure that the training of future pediatric intensivists includes all aspects of patient care, education, research, and leadership and that this training takes place within the context of the duty-hour restrictions.
In developing a curriculum that allows understanding and utilization of the core competencies by trainees as well as continuing medical education for practitioners, the approach to teaching and feedback should be based on principles of adult learning (Box 17-1).15 Adult learning is fundamentally different from childhood learning, and though a continuum between these two types of learning could be argued, the difference between them is based on several key distinctions. Adult learners have a greater depth and breadth of experiences and knowledge upon which to draw and relate new experience and learning.15,16 To assimilate new information, adults need to be able to integrate new ideas with what they already know. Furthermore, information that conflicts with what is already believed to be true is integrated more slowly.17
Box 17–1 Principles of Adult Learning
Adults are self-directed and autonomous. As a consequence, their education is typically most effective when programs facilitate self-learning with specific goals of acquiring practical information. Motivation for learning is both intrinsic (personal need for new knowledge base or skill set) and extrinsic (professional expectations from colleagues or authority figures). Adults benefit from an appropriately challenging learning environment.16,17
Adults learn best when they are active participants in the learning process and are allowed to practice newly acquired skills and concepts.16,18 Adults have varied experiences and knowledge and do not all learn in the same way. Therefore, a multimodal approach to teaching with multiple exposures to content is more effective than any single approach/exposure method. Finally, adult learners require and often seek out feedback, and therefore they learn more effectively when given timely feedback that reinforces newly acquired information.
Stuart Dreyfus, an applied mathematician, and Hubert Dreyfus, a philosopher, developed a model of skill acquisition based on their studies of fighter pilots.19 This model addresses the stages in the development of professional skills. In addition to being studied in fighter pilots and military personnel, the model has been studied in chess players and car drivers; more recently it has been applied to skill acquisition in clinical medicine. The Dreyfus model proposes that skill acquisition is not different from the continuum of human development, with stages of skill acquisition designated as novice, advanced beginner, competent, proficient, expert, and finally, master. The learner needs to acquire certain skills and learn certain concepts at each level; therefore, teaching methods must match the level of development (Table 17-1).
PCCM, Pediatric critical care medicine.
Adapted from Carraccio CL, Benson BJ, Nixon LJ, et al: From the educational bench to the clinical bedside: translating the Dreyfus Developmental Model to the learning of clinical skills, Acad Med 83:761-767, 2008.
It is incumbent upon those who oversee the ICU to be responsible for the education of those who occupy it. There are different levels of learners and educators. The faculty physician is the expert or master and serves as the facilitator/educator for medical students, residents, fellows, nurses, and other allied health personnel. This tenet requires the faculty physician to strive constantly to attain and maintain the expert or master status. To have effective teaching in the ICU, the faculty physician must understand that a gap often exists between what faculty physicians and trainees perceive as adequate teaching.20 Furthermore, one must overcome traditional barriers to education, which include lack of dedicated teaching time, high clinical workload, and poor continuity between faculty physicians and trainees,20 especially with the requirement of alternative scheduling, such as shift work, to accommodate the 80-hour work week.11
Education in the ICU setting consists of teaching basic principles but also includes an ongoing, ever-changing process that depends on new literature and accumulation of medical knowledge. Teaching tools should be designed and selected to optimize improvement of both physician performance and health care outcomes.18 A learning needs assessment is crucial to effective continuing medical education (CME) and interactive learning associated with opportunities to practice learned materials/skills in an environment that offers sequenced and multifaceted activities.18 A systematic review that evaluated 37 studies of CME showed that “multiple media, multiple techniques of instruction, and multiple exposures to content are suggested to meet instructional objectives intended to improve clinical outcomes.”21 Many of the features that are instrumental in successful CME initiatives are also principles of successful adult learning. Hence, the tools necessary for educating intensivists should include these principles. Current teaching methods were assessed by a survey of critical care medicine program directors (pediatric, surgery, medicine, and anesthesia), and Table 17-2 summarizes the methods used. The most common method of teaching in the ICU is the bedside, case-based approach, with 80% of programs spending at least 2 hours a day on this activity.11 Of the methods listed, 45% of the programs wished to have computer or human patient simulation, and 50% would incorporate more Web-based learning modules, which have been shown to be efficacious.22 Other tools or teaching strategies include debriefing in the ICU,23 competency-based conference morning report,24 and changing didactic schedules to accommodate nonstandard work sessions (i.e., shift work).25
|Bedside, case-based teaching||94.4|
|Morbidity and mortality conference||72.6|
|Syllabus of articles||63.7|
|Psychomotor skills laboratories||24.0|
|Palm pilot algorithms||3.2|
Modified from Chudgar SM, Cox CE, Que LG, et al: 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 37:49-60, 2009.
In 2004, the Society for Critical Care Medicine released “Guidelines for critical care medicine training and continuing medical education,”26 which addressed the needs of physician education in critical care medicine on a continuum from the resident to the intensivist. Table 17-3 is a representation of the broad scope of educational objectives for critical care medicine fellows and intensivists that includes two broad areas of learning: clinical and administrative.
|Identify and teach others to identify the need for/provide care for all critically ill patients||Evaluate current ICU hospital policies and suggest improvements|
|Provide and teach others resuscitation for any patient sustaining a life-threatening event||Triage critically ill patients to optimize care delivery within the institution|
|Initiate, manage, and wean patients from mechanical ventilation and teach others new methods and devices for management of respiratory failure||Improve resource utilization and maintain patient care quality by facilitating triage of patients to limited institutional critical care beds and caregivers|
|Initiate critical care to stabilize and manage patients who require transport||Develop programs and change unit practice to improve care of critically ill patients|
|Instruct other qualified caregivers and the lay public in the theory and techniques of CPR||Develop programs for patient safety monitoring and error reduction|
|Treat cardiogenic, traumatic, hypovolemic, and distributive shock with conventional and state-of-the-art approaches||Actively participate in quality assurance processes, including morbidity and mortality conferences, process improvement teams, and Joint Commission Accreditation of Healthcare Organizations preparation|
|Recognize the potential for multiple organ failure and institute measures to avoid or reverse this syndrome||Support the process of assessing patient and family satisfaction and participate in tool development and implementation|
|Identify life-threatening electrolyte and acid-base disturbances, provide treatment, and monitor outcome||Encourage and enhance good relationships with other health care providers|
|Identify and initiate discussions involving ethical issues and parent/patients’ wishes in making treatment decisions using advance directives and other methods||Understand advanced concepts important for compensation of critical care services and contractual issues related to providing critical care services and performing the business of medicine|
|Diagnose and treat common and uncommon poisonings||Develop skills for teaching critical care|
|Teach appropriate use and monitoring of procedural sedation and use advanced pain management strategies||Develop and evaluate curriculum changes for ICU caregivers, fellows, and residents|
|Diagnose malnutrition and use/monitor advanced nutrition support methodologies||Evaluate, modify, and approve ICU hospital policies|
|Provide invasive and noninvasive monitoring for titrating therapy; prioritize complex data to support action plan||Improve resource utilization and maintain patient care quality by planning for future needs for institutional and regional critical care resources|
|Use and teach medication safe practice guidelines and determine cost-effectiveness of therapeutic interventions||Develop programs and change unit, institution, and regional practice to improve care of critically ill patients|
|Develop skills of ICU nurses and ancillary personnel in caring for critically ill patients and provide in-service education||Use existing tool sets to assess patient and family satisfaction and direct the development of new tools when appropriate|
|Use, teach, and help enforce methods of infection control||Develop programs and document improvement in patient safety monitoring and error reduction|
|Communicate effectively with patients, families, and other involved members of the health care team about all treatment decisions and patient prognosis||Develop high-quality relationships with other health care providers|
|Continue to augment knowledge by assimilating peer-reviewed published medical literature through self-directed learning and CME activities||Teach the business of medicine|
|Diagnose and treat a sufficient number of patients with critical illness using conventional and state-of-the-art approaches to maintain clinical proficiencies||Develop collaborative and productive relationships with other specialist physicians and model joint clinical planning in managing complex ICU problems|
CME, Continuing medical education; CPR, cardiopulmonary resuscitation; ICU, intensive care unit.
Adapted from Dorman R, Angood PB, Angus DC, et al: Guidelines for critical care medical training and continuing medical education, Crit Care Med 32(1):263-272, 2004.
Case-based teaching at the bedside is thought to be one of the most effective means of educating clinicians in the understanding of disease processes and evaluation and management of critically ill patients. Nothing is more dramatic and unforgettable than seeing a patient with fulminant meningococcemia and purpura fulminans. Perhaps less dramatic but just as effective are instances when one palpates a thrill, hears a gallop, feels an enlarged liver or spleen, listens to wheezing or stridor, or performs a detailed neurologic examination in a patient who has experienced a middle cerebral artery stroke or a spinal cord injury. Even medical technology is better taught at the bedside. When the learner is introduced to a child with severe asthma exacerbation who is receiving mechanical ventilation and the learner is shown the flow volume loops exhibited at various ventilator rates and inspiratory:expiratory ratios, she or he is likely to come away with a much better understanding of the principles of mechanical ventilation in someone with a prolonged time constant. The different waveforms on bedside monitors can be used to demonstrate important pathophysiologic principles. Examples include malignant intracranial pressure waveforms with a wide systolic-diastolic variation reflecting the poor compliance of a diffusely swollen brain; the lack of a dicrotic notch in the arterial waveform of someone with hypovolemia; changes in systolic pressure associated with inspiration in a patient with pulsus paradoxus; and the right ventricular tracing of a subclavian venous catheter meant to be in the right atrium that has been inserted too far. Showing trainees extracorporeal membrane oxygenation circuits, continuous veno-venous hemodialysis and ultrafiltration machines, high-frequency oscillators, and ventricular assist devices while they are being used in patient care provides the “aha” moment often not attained while viewing slides in a darkened room during a lecture.
In addition, when trainees present the historical data and physical findings of their patients to the attending physician during bedside rounds, they can be taught to describe the information relating to their patients in a succinct manner and discriminate between important and less important information, develop a list of differential diagnoses, and formulate a treatment plan. They learn to “think on their feet” and can be taught how to put data together to determine a cohesive diagnosis that will lead them to the right conclusions regarding diagnostic and management decisions.
In these days of duty-hour limitations, electronic medical records, and computerized order entry, it is easy to lose sight of the patient and stray from the bedside. However, clinical acumen remains largely dependent on exposure to a large number of clinical cases in building medical knowledge and experience in each learner, no matter what level they are at. Therefore, case-based bedside teaching should always be a major component of clinical teaching. Historically, patients have always been and should continue to be our best teachers.