Lifelong learning in pediatric critical care

Pearls

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The practice of pediatric critical care medicine requires a broad knowledge base and skill set that necessitates lifelong learning throughout an intensivist’s career to achieve mastery.
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Based on adult learning principles, education efforts should emphasize active participation and practice, examples of which include bedside teaching, procedural training, debriefing, and simulation.
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Training in critical care medicine should reflect a structured process that progressively transfers increasing levels of responsibility for decision-making to the learner.
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Entrustable professional activities describe an ability to perform a task or responsibility without direct supervision once sufficient competency is attained. Milestones provide behavioral descriptors that indicate developmental progression along competencies.
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Continuing medical education and maintenance of certification programs are working together to incorporate adult learning principles.
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The mature clinician reflects on one’s daily medical experiences to place them in a larger context of previous encounters and critically evaluates one’s own performance, acknowledging both effective and ineffective aspects of patient care.

Pediatric critical care medicine (PCCM) is a discipline dedicated to the care of the critically ill child, focusing on the sick child as a whole and including the impact of disease on all organ systems. In addition, pediatric intensivists must address and understand the physical, mental, and emotional needs of the child and the child’s family. The complex needs of the critically ill child also require that intensivists be prepared to assume a leadership role in the coordination of care among team members from multiple disciplines. The pediatric intensivist must 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 be knowledgeable in patient safety and quality improvement methodology and lead these efforts in the intensive care unit (ICU) environment. Skills for evaluating medical literature, clinical and/or basic science research, and the ability to teach learners at different levels and from a variety of disciplines effectively are also invaluable. Development of this complex array of knowledge and skills begins in medical school, with the goal of mastery over the course of an individual’s career. Becoming a master in the specialty of pediatric critical care hinges on lifelong learning , which implies that the described individual has a voluntary interest in self-development and learning for the sake of learning. This enjoyment associated with learning is thought to be moldable and able to be influenced, even developed and promoted through the use of adult learning principles.

Adult learning theory in medical education

Adult learning theory was theorized and modeled by Malcom Knowles in the 1970s. He identified six principles of adult learning ( Box 10.1 ). Knowles drew on the work of Kolb, using these principles to emphasize that there is not a one-size-fits-all approach to learning. For example, the reader might imagine two individuals who purchase a new electronic device. Whereas one may take the device out of the box, immediately turn it on, and begin experimenting with its features, the other purchaser may not even remove it from the box before reading the entire instruction manual. Adult learning theory celebrates the differences in the approach to learning while making these differences overt and explicit. In designing and implementing curricula and assessments, medical educators may design curricula and evaluations that use these concepts. Kolb described effective learning as a progression through a cycle of stages—having a concrete experience, followed by reflection on that experience, leading to information synthesis and future testable hypotheses. For those familiar with quality improvement principles, it is not unlike plan-do-study-act, in which small tests of change are implemented, observed, and the necessary modifications determined.

• BOX 10.1

Knowles Principles of Adult Learning

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Adults are:
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  internally motivated and self-directed
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  goal oriented
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  relevancy oriented
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  practical
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Adults bring life experiences and knowledge of learning experiences
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Adult learners like to be respected

Building on these principles, a key element of medical education is to use learner assessment to drive teaching methods. Stuart and Hubert Dreyfus developed a model of skill acquisition based on their studies of fighter pilots. 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 have to match the level of development ( Table 10.1 ).

TABLE 10.1

Dreyfus and Dreyfus Model of Skill Development Applied to the Development of a Competence in the Subspecialty of Critical Care Medicine

Modified from Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: Translating the Dreyfus developmental model to the learning of clinical skills. Acad Med . 2008;83(8):761–767.

Level of Learning and Characteristics	Examples of Learner Level in Critical Care Medicine	Teaching Implications
Novice Rule driven Uses analytical reasoning and rules to link cause and effect Synthesis of information is based on knowledge acquired during residency training Big picture elusive	First-Year Fellow Interviews patient and performs a physical exam that is focused on the critical illness May not be able to focus the information on the basis of a differential diagnosis Does not see the big picture	Teach basic critical care concepts Point out subtle but meaningful diagnostic information in the history and physical examination Eliminate irrelevant information Highlight discriminating features and their importance to the diagnosis Encourage reading about 2 diagnostic hypotheses at the same time
Advanced Beginner Sorts through rules and information to decide what is relevant on the basis of past experience Uses analytical reasoning and pattern recognition to solve problems Able to abstract from concrete and specific information to more general aspects of a problem	Second-Year Fellow Can generate more specific differential diagnosis while obtaining history and physical exam Capable of filtering relevant information to formulate a unified summary of the case Can abstract pertinent positives and negatives from the review of systems and incorporate them into the history of present illness	Expose learner to clinical cases proceeding from common to uncommon Emphasize the use of semantic qualifiers Encourage formulation and verbalization of differential diagnosis and treatment plan Good coaching: help learner become attentive to the meaningful pieces
Competent Emotional buy-in allows learner to feel appropriate level of responsibility More expansive experience tips the balance on clinical reasoning from methodical and analytic to identifiable pattern recognition of common clinical problems Sees the big picture Complex/uncommon problems still require reliance on analytical reasoning	Third-Year Fellow Recognizes common patterns of illness based on previous encounters Sees consequences of clinical decisions, which leads to emotional buy-in to learning Will methodically attempt to reason through complex or uncommon problems Responsible for decision-making process	Balance supervision with autonomy in decision-making Hold learners accountable for their decisions Do not tell learners what to do; ask what they want to do Critical for learner to see a breadth and depth of patient encounters to construct and store in memory a large repertoire of illness scripts Tip the balance from clinical reasoning to pattern recognition
Proficient Breadth of past experience allows reliance on pattern recognition of illness Problem solving intuitive Still needs to fall back to methodical and analytic reasoning for managing problems because exhaustive number of permutations and responses to management have provided less experience in this regard than in illness recognition Is comfortable with evolving situations, able to extrapolate from a known situation to an unknown situation Can live with ambiguity	Clinical Instructor Starts to match findings with those encountered in past experience Data gathering more effective and efficient Sees patient through different lens than the student Engages in process of clinical reasoning to find the best intervention	Needs to work alongside and be mentored by an expert Must develop capacity to know ones’ limitations and step back and call on additional resources when stretched beyond one’s capabilities
Expert Thought, feeling, and action align into intuitive problem recognition and intuitive situational responses and management Open to noticing the unexpected Clever Discriminates features that do not fit a recognizable pattern	Assistant Professor Broad repertoire of illness scripts, based on clinical experience that allows immediate action for majority of clinical encounters Likes to deal with diagnostic dilemmas When presented with diagnostic dilemma, will slow down and look it up	Keep up the challenge Needs ongoing experience and ongoing exposure to interesting and complex cases to avoid complacency and to help transcend beyond this level Should be apprenticed to a master who models the skills of the reflective practitioner and a commitment to lifelong learning
Master Exercises practical wisdom Goes beyond the big picture to that of culture and context of each situation Deep level of commitment to the work Great concern for right and wrong decisions that fosters emotional engagement Intensely motivated by emotional engagement to pursue ongoing learning and improvement Reflects in, on, and for action	Associate Professor/Professor The clinician that everyone goes to with problem cases Recognizes subtle features of a current case reminiscent of cases seen over the years Painstakingly revisits past cases or identifies common thread that will help treat the current clinical problem Vision extends beyond individual practice Contributes to bigger context to improvements in the field Intense internal drive to learn and improve Practical wisdom	Self-motivated to engage in lifelong learning and practice improvement

Adult learning is fundamentally different from childhood learning because of the greater depth and breadth of experiences and knowledge on which adults build new experiences. ^, In order to assimilate new information, adults must be able to integrate new ideas with what they already know, and information that conflicts with this knowledge may not be quickly integrated. Adults are self-directed and autonomous. They learn best when they are active participants in the learning process and are allowed to practice newly acquired skills and concepts. ^, As a consequence, education for adults is typically most effective when programs facilitate self-learning with specific goals of acquiring practical information.

Efforts to be inclusive of curricular methods that support adult learning principles are occurring in undergraduate, graduate, and continuing medical education. Problem-based and small-group learning, flipped classrooms, and simulation exercises allow many venues for reaching learners in different ways. Didactic learning remains firmly in place. It should be emphasized that no one method of instruction has been definitively proven to produce better learning outcomes than another. Table 10.2 depicts varied instructional techniques with potential benefits and costs.

TABLE 10.2

Instructional Techniques According to Potential Costs and Benefits

			Potential Benefits	Potential Costs
Didactic learning	Traditional lecture	Teacher led	Easy to organize Inexpensive (both in teacher time and facility cost) Allows for independent learning	Noninteractive Noncollaborative
Problem-based learning	Small group cases	Student led Teacher facilitated	Active learning Motivation for learning Allows for complex thought Collaborative and interprofessional	Facilitator skill required High faculty, time, and space costs Students may have different styles and learning needs that are incompatible
Team-based learning	Out-of-class preparation followed by in-class application	Student led Teacher facilitated	Active learning Motivation for learning Allows for complex thought Collaborative and interprofessional Multiple assessments	Facilitator skill required High faculty, time, and space costs Advance student preparation required Students may have different styles and learning needs that are incompatible
Simulation	Practice of scenarios in simulated environments	Teacher led Students active	Hands-on skills practiced Literature from other industries (airlines) supports utility Collaborative and interprofessional	Resource and time expensive Can seem contrived/unrealistic
Social media	Online Internet platform for knowledge sharing and discussion	Student and teacher facilitated	Real-time discussion Collaborative and interprofessional Instant access and knowledge of most up-to-date literature	Potential distraction Not curated or monitored

If assessment truly drives learning, medical educational curricula must be increasingly grounded in the assessment of knowledge and skills acquisition, now defined as abilities (or entrustable professional activities) and composed of individual competencies. For example, one could consider a teenager first learning to drive a car. The teenager must be competent in many individual areas, such as knowledge of the laws of the road and the skills of braking, using turn signals, mirrors, and seatbelts before embarking on this activity and being entrusted to drive the car. Like supervising a learner performing a technical procedure on a critically ill child, the trust that a parent affords a child in independent driving is fluid. The teenager may initially receive parental permission for driving around the neighborhood. When demonstrating responsible and safe driving conduct, the teenager may gain parental trust to drive on the freeway or with friends. Likewise, the graduated autonomy that a supervising intensivist will allow learners in performing central line placement will vary according to individual knowledge and skills, but it is also highly contextual. As is reflected in the 2004 guidelines for critical care medicine training and continuing medical edition published by the Society for Critical Care Medicine, training in critical care medicine should reflect a structured process that progressively transfers increasing levels of responsibility for decision-making and that ensures continued training in practical aspects of care.

Graduate medical education

The landscape of graduate medical education (GME) has dramatically evolved since its apprenticeship/house officer origins in the early 1900s. In the past decade, increasing scrutiny has been placed on GME, with a specific focus on duty hours. In 2011 the Accreditation Council for Graduate Medical Education (ACGME) placed restrictions on duty hours in an effort to increase safety for patients and learners based on some data to suggest that sleep deprivation and fatigue causes errors, and that alertness and performance vary within different points in the circadian rhythm. These restrictions undeniably changed the landscape of learning. For example, duty hour regulations led to an increase in the number of times that care of a patient was transferred to a different provider, which prompted educational reform around transitions of care with programs such as I-PASS (illness severity, patient summary, action list, situational awareness, and synthesis by receiver). Following two large randomized control trials showing noninferiority with regard to patient outcomes and resident satisfaction or well-being, ^, the ACGME issued revised guidelines in 2017, allowing for more flexibility with regard to duty hours and, most importantly, stressing the importance of teamwork, physician well-being, flexibility, and patient safety. Along with changes in expectations around hours worked, expectations for GME programs have also evolved to focus more on patient safety, quality, and teamwork, along with the traditional specialty- and subspecialty-specific content that is important for new physicians.

Accreditation council for graduate medical education core competencies, milestones, and entrustable professional activities

The quality of education in training programs is critical to resident and fellow development. In 1999, the ACGME initiated an outcome project to design a conceptual framework for education and training according to six general domains of competency . The objective of the outcome project was to “ensure and improve the quality of GME.” The ACGME recommends that trainees demonstrate (1) patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health; (2) medical knowledge regarding established as well as evolving biomedical, clinical, and cognitive sciences with the ability to apply these concepts to patient care; (3) practice-based learning and improvement involving self-evaluation with regard to patient care, appraisal, and utilization of scientific evidence; (4) interpersonal and communication skills that result in effective information exchange and partnership with patients, their families, and other health professionals; (5) professionalism manifested through a commitment to professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population; and (6) an awareness of and responsiveness to the healthcare system and the ability to use system resources to provide optimal care in a systems-based practice . These core domains of competency should be used to guide and coordinate evaluation of all residents or fellows in their development.

In order to fulfill the promise of the Outcome Project to use educational outcome data in accreditation, the Pediatric Milestone Project, a partnership between the ACGME and American Board of Pediatrics (ABP), was designed for the evaluation of resident physicians participating in ACGME-accredited residency or fellowship training programs. Milestones, which are now routinely used in GME evaluations, describe the performance levels that residents and fellows are expected to demonstrate for skills, knowledge, and behaviors in the six competency domains . They are intended to provide a developmental framework of observable behaviors and attributes for learner assessment. Although they are not intended to address all competencies, milestones are anchored contextually in the development of the physician in key elements of the competencies.

The use of milestone assessment has a number of benefits for residents and fellows, including increased transparency of performance requirements by more explicit expectations, better feedback, and enhanced opportunities for early identification of underperformers.

In addition to the milestones, which have now become standard assessment tools in GME training, most specialties and subspecialties have begun developing entrustable professional activities (EPAs), which can be defined as a representation of the tasks associated with all of the work within a specific field. ^, Leaders in pediatrics and the pediatric subspecialties, through the work of the ABP, have developed a set of EPAs for both pediatrics and for the pediatric subspecialties. PCCM has three subspecialty-specific EPAs, which supplement several EPAs that cross all specialties, along with those for general pediatrics. While EPAs have not yet become a standard method for assessment of learners, data are beginning to emerge on their implementation and use as an assessment tool in this specialty. ^,

Methods of teaching

Given the complexity of the ICU environment and the wide range of learners and educators, leaders of training programs should consider the importance of the quality of teaching methods. The faculty members responsible for supervision in the ICU are the content experts and are often also expected to be the facilitators/educators for learners at a range of levels and from a variety of disciplines. To be an effective educator, there must be a clear understanding that a gap often exists between educators and learners regarding perceptions of adequate teaching and optimal teaching techniques. One must overcome recognized barriers to education, which include lack of dedicated teaching time, high clinical workload, lack of continuity between faculty and learners, and balancing autonomy and supervision. These factors are increasingly challenging in the current era.

Education in the ICU consists of teaching basic principles of pathophysiology and therapeutics but should also include an ongoing, dynamic integration of new medical knowledge and technological advances. Table 10.3 demonstrates the broad scope of educational objectives for critical care medicine fellows and intensivists per the guidelines from the Society of Critical Care Medicine and includes two broad areas of learning: clinical and administrative. Teaching tools should be designed and selected to optimize improvement of both physician performance and healthcare outcomes. Curricular development should focus on development of effective programs that include sequenced and multifaceted activities. A review that evaluated 37 studies of continuing medical education activities demonstrated that the use of multiple media, a variety of instructional techniques, and exposures to content to meet instructional objectives are all needed to improve clinical outcomes. A recent review of teaching techniques in critical care demonstrates the importance and benefit of multiple interactive strategies that apply principles of adult learning. ^, The practice of medicine is evolving at a rapid pace, and teaching strategies must also continue to evolve. While bedside teaching and didactic lectures are important, innovative strategies are needed to maximize education in the current era. For example, debriefing is a teaching strategy that is integrated into simulation-based education and is increasingly being used within the context of clinical care in the ICU to teach important principles. A debrief is a review of a situation led by an experienced facilitator to allow learners to explore steps that went well and identify opportunities for improvement and learning. A survey of PCCM program directors demonstrated that faculty role modeling is the most common technique used in pediatric critical care programs to teach the competencies of professionalism and communication.

TABLE 10.3

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