Medical education and its delivery have become points of emphasis for both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics (1). Resident work-hour restrictions, although important for patient safety and resident work–life balance, limit the available time for structured resident education. Residency programs are now faced with the challenge of how to cover the same amount of information with fewer contact hours. This task becomes even more difficult for subspecialty rotations, which often last only 1 month (2).
At many institutions, the teaching provided on subspecialty gastroenterology rotations is not structured and depends on the willingness and teaching skills of individual faculty members. In addition, teaching on rounds can be affected by the patient mix as well as patient volume. Teaching focused on inpatient issues may not cover topics most applicable to the knowledge required of a general pediatrician who is likely to see large numbers of children with constipation but few with inflammatory bowel disease.
At the same time, the more traditional teaching method of didactic lecture has come under criticism for not being conducive to adult learning. Numerous studies demonstrate that adults favor more interactive, case-based instruction, hands-on learning, and self-directed learning (3–5).
The establishment and testing of educational curricula for pediatric residents involved in various subspecialties has been discussed in the medical literature. Cullen et al (6) described the effectiveness and time investment of a curriculum for residents in the pediatric intensive care unit. There have also been numerous published studies on the effect of structured curricula in the fields of developmental pediatrics, nutrition, and rheumatology (4,7–9). Wigton (10) described the effect of a gastroenterology lecture series on the performance of internal medicine residents after a 1-month rotation. The present study found no difference in the residents’ performance on objective testing compared with another group who did not receive the lectures, although the involved residents did rate the experience as “greatly educational.”
There are no published studies discussing education within a pediatric gastroenterology subspecialty rotation. The purpose of the present study was to describe the development, implementation, and assessment of a structured gastroenterology curriculum for pediatric residents, highlighting the use of fellows as teachers within the curriculum.
This is a 1-group pretest, posttest, and survey-based study of a new gastroenterology curriculum developed for pediatric residents during their gastroenterology rotation as part of a general pediatric residency program.
At our institution, 4 second-year pediatric residents rotate through the inpatient gastroenterology wards and outpatient clinics each month. Residents are responsible for caring for inpatients on the combined hepatology/transplant service as well as children on the lumen service, which include more traditional gastroenterology patients such as those with inflammatory bowel disease, failure to thrive, and severe constipation. Residents also spend 2 to 4 half-days in the outpatient gastroenterology clinic.
Pediatric gastroenterology topics were considered based upon the guidelines listed by the American Board of Pediatrics (11). Using the Kern model for curriculum development, we performed a needs assessment to determine what gastroenterology topics would be considered most important to general pediatricians (12).
Graduates from the Cincinnati Children's Hospital Medical Center pediatric residency program between the years of 2001 and 2005 who entered primary care in pediatrics (n = 86) were sent a survey via email and standard mail. Participants had the option to complete the survey using either a paper form or the Internet-based surveymonkey.com. The survey asked pediatricians to rate their opinion of their preparedness to manage patients with issues relating to gastroenterology, hepatology, and nutrition such as constipation, reflux, and failure to thrive. Responses were rated on a 5-point Likert scale with a score of 1 being “not prepared at all”; a score of 3 being “generally prepared”; and a score of 5 being “very well prepared.” Participants were also asked to estimate the percentage of their practice time spent managing these patients with gastrointestinal problems. The survey also asked pediatricians to list the 5 most common gastrointestinal (GI) topics they encounter within their practice not including acute infectious gastroenteritis or diarrhea. Finally, the pediatricians were asked to list gastroenterology topics they wished had been covered in more detail during their residency.
The creation and implementation of the subspecialty curriculum was done as part of the primary author's (S.P.) master's degree of medical education coursework during a 3-month period. Curricular topics were chosen based on the results of the resident surveys.
A literature search was performed for each topic, particularly for established guidelines. A sample case presentation or a set of cases was created to give the residents a frame of reference. The format of the cases was primarily question and answer to stimulate interaction and discussion from the residents. Residents were provided with handouts and articles for references at the end of the discussions for future use.
In addition to teaching during inpatient rounds, residents attended 2 30-minute teaching sessions and 2 45-minute teaching sessions per week (16 sessions total) for a total of 10 hours of structured curriculum per month. These sessions were presented at the same time as morning report and the noon conference where the general pediatric curriculum is presented. Residents were presented with information using a variety of teaching techniques based upon adult learning principles. These included interactive case-based discussions, short didactic teaching sessions, and self-directed learning cases, and topic reviews. Instructional materials, including goals and objectives for each teaching session, were created by several of the teaching faculty and then stored on a shared computer drive where they could be easily accessed by all of the instructors (online-only appendix, http://links.lww.com/MPG/A68). Attendance was noted to ensure that residents were maintaining their mandatory conference attendance requirement.
Residents were also responsible for the creation of their own 30-minute case presentation on a gastroenterology topic of their choice, which was given to their peers as part of the general residency “morning report” series. This project was supervised by attending faculty on the inpatient service.
Teaching sessions were taught primarily by second- and third-year gastroenterology fellows (total 8 fellows per year) with additional sessions taught by faculty, dietitians, pharmacists, and nursing staff. A calendar was circulated monthly and teachers signed up for slots, which fit his or her schedule. No member of the teaching team was required to lead >1 session per month. Fellows were intermittently observed by faculty but primarily taught sessions independently.
Evaluation and Feedback
Residents completed anonymous evaluation forms each month detailing their opinions about the value of the curriculum and suggestions for change. Starting in July 2010, residents were also given evaluation forms after the individual talks to rate the content and clarity of the presentation. These topic conference evaluations asked the residents to evaluate the objectives of the talk, whether it was case-based and interactive, and its perceived usefulness using a Likert scale.
Residents also had face-to-face feedback sessions with a faculty member (S.P.) and a chief resident at the end of each month to discuss the overall rotation. These sessions included discussion of the educational curriculum. Comments from the residents were transcribed to identify common themes.
Residents were given a 30-question multiple-choice pretest based upon material covered as part of the curriculum at the beginning of the rotation and again at the end of the month to help measure change in their knowledge. Before implementation of the new curriculum, the pre-posttest was pilot tested on a small sample of residents (n = 5) for clarity and timing. Results of the pre-posttest were collected during a 1-year period (July 2007–June 2008).
This new curriculum has been ongoing for 4 years (2006–present). More than 150 pediatric residents have experienced the rotation. Twenty fellows and 4 faculty attendings have been involved as teachers.
Survey Results and Topic Selection
Thirty-one former pediatric residents (36%) completed the survey (Table 1). More than half of the respondents had graduated from pediatric residency in the last 2 years. Respondents generally felt that their knowledge was average (3.5/5) on the topics of nutrition, vomiting, gastroesophageal reflux disease, failure to thrive, abdominal pain, poor weight gain, and obesity. They felt most confident managing constipation and infant jaundice (average scores of 4.5/5) and the least confident with allergic disorders and the care of gastrostomy tubes (mean score of 2.8/5). Alumni estimated that 10% to 25% of their patients presented with GI complaints per day (excluding gastroenteritis). They listed their most commonly encountered GI illnesses as gastroesophageal reflux disease, constipation, diarrhea, abdominal pain, and infant jaundice.
Curriculum topics were chosen based upon survey information (Table 2). The curriculum specifically addressed the alumni's perceived weaknesses in the management of gastrostomy tubes and nutrition in GI patients as well as the disorders that were listed as most common. The authors estimated that the creation of each topic took approximately 4 hours, although this did vary depending on the material. The time involved in creating and updating the monthly resident education calendar was generally 1 hour/month.
Evaluation and Feedback
Based upon the anonymous monthly surveys, resident evaluation scores of the quality of the education on the GI team remained stable with an average rating of 4 of 5 following the implementation of the standardized curriculum. No difference was noted between evaluations of fellow teachers compared with those conferences taught by faculty, although the return of evaluations was low.
During the monthly feedback sessions, residents gave primarily positive feedback. Common themes from the residents were that the topics covered material they needed for the rotation and also were valid for general pediatrics. Residents reported that they preferred the interactive, discussion group format. No negative remarks were received about the use of fellows or nonattending staff as teachers during the rotation. Several of these individuals were consistently noted by residents to be excellent teachers.
After the first 6 months of feedback, 2 topic changes were made based upon resident feedback. Residents asked for more specific talks on both chronic liver disease and short bowel syndrome because they frequently cared for these patients during the inpatient rotation. The topics of fluids and electrolytes and failure to thrive were removed because the residents reported that these areas were covered either outside the rotation or during the rotation itself. The topic of eosinophilic esophagitis was later combined with the discussion of gastroesophageal reflux disease as part of further resident feedback.
A common early criticism of the curriculum reported at the feedback sessions was that the residents would have preferred for certain lectures to be given earlier in the month. This included primarily talks on hepatology because the residents had little previous exposure to these topics. This was improved in later months.
Another concern was that the gastroenterology curriculum sessions occurred at the same time as the regular general pediatrics conferences. Although this concern was common, residents believed there was not a more available time in their daily schedule for this teaching without affecting patient care and violating work hours.
The pretest and posttest results were also collected and evaluated after 1 year. Thirty-one pretests were collected with an average of 20.8 (range 11–28). Due to poor return of posttests, only 16 matched pre-posttests were available for comparison. Pretest scores from the matched sample averaged 20.5 (range 14–24) and posttest scores were 22.6 (range 17–28), which was significant by paired t test (P = 0.0002).
The time required for the face-to-face feedback was 1 hour/month. Pre-posttest results and the anonymous resident survey results were evaluated every 3 to 4 months.
We developed a sustainable, adult-learning-oriented approach to a subspecialty curriculum. The curriculum also fits within present work hour restrictions and gives GI fellow trainees opportunities to improve their teaching skills.
Important factors for the success of the curriculum include the needs assessment and the frequent feedback/evaluation we received from the residents. The survey of general pediatricians and later feedback from active residents within the program allowed the curriculum topics to be relevant and more learner-centric. The monthly feedback and evaluation, including the pre-posttest, gave us the opportunity to determine the effectiveness of the curriculum as well as institute changes.
Although statistically significant, the modest improvement from the pretest to posttest was concerning. Although materials, including the test questions, were provided to the fellow and faculty teachers as part of their preparation, they were not asked to “teach to the test.” These results are similar to the findings of Wigton et al (10) and the small improvement may instead represent that the standardized testing format is not a good reflection of knowledge gained by the curriculum. Our residents score highly on the gastroenterology portion of their yearly in-service examinations, which reflects a strong knowledge base before the gastroenterology curriculum. Thus, it may be that they score highly on the pretest, which makes it more difficult to discriminate improvement after the curriculum.
During the feedback sessions, a common theme from the residents was concern that the subspecialty curriculum was presented at the same time as the general pediatrics curriculum. At the same time, they recognized that there is decreased available time overall for both formal general pediatrics education and subspecialty education as a result of the decrease in resident contact hours. This time constraint generally mandates morning report and noon conference times to be dedicated to general pediatrics resident education. This conflict with the gastroenterology curriculum is mitigated somewhat by the timing of the general pediatrics curriculum, which is presented in an 18-month cycle so that residents have the opportunity to attend conferences they missed as a result of other educational and clinical responsibilities. Also, nursing staff members are aware that the residents are involved in conferences during these times and attempt to limit pages, which should lead to fewer distractions.
A variety of other methods have been developed to help combat both the need for structured subspecialty educational curricula and the increasingly limited available time for resident education. These include Web-based learning exercises and simulation, which the residents can do at their own pace and outside working hours. Studies have shown that students feel that online learning should supplement, not replace, traditional face-to-face teaching maintaining the need for live, interactive student-teacher educational activities (13,14).
We believe that the use of fellows as teachers in our curriculum is a strong point. This has been documented by Kempainen et al (15), with subspecialty fellows teaching a respiratory curriculum to medical students. This idea greatly increased the pool of available teachers and balanced the time commitment to 30 to 45 minutes/month for individual instructors, not counting preparation time. In our program, a 1-day educator development workshop is offered to clinical fellows and many find this a helpful experience. Many of the fellows expressed readiness to teach based on their participation in teaching during rounds during their first year of fellowship and as residents themselves. Despite having available materials shared online, several fellows independently created their own teaching tools.
In a 2007 survey of graduating pediatric gastroenterology fellows, the majority reported giving between 11 and 20 lectures total during their entire fellowship (16). By participating in the resident education curriculum, our gastroenterology fellows were easily able to give more than twice this number of talks during their fellowship training.
Because curricula are always changing to meet the needs of the learners, future directions will include the creation of additional Web-based modules to supplement the present topics. In addition, we continue to develop the means to evaluate the fellows’ teaching skills by both the residents and faculty, which is another under-recognized and valuable educational tool.
Finally, it was not our objective to compare our curriculum with other programs. We hope that this curriculum may serve as a guide for other medical educators in gastroenterology who also face the challenge of educating residents within a limited time frame. Because there remains a dearth of information in the medical literature regarding the development and implementation of subspecialty curricula, we would also like to encourage more collaboration and sharing of teaching materials and ideas among subspecialty programs similar to our basic science and clinical research counterparts.
In summary, we found that the creation of a structured subspecialty curriculum using a needs assessment to establish the appropriate curricular emphasis along with the use of fellows as teachers is feasible, sustainable, and effective despite limitations in available time for resident teaching.
1. Balistreri WF, et al. Pediatric subspecialty training fellowships at Cincinnati Children's Hospital Medical Center (CCHMC). J Pediatr 2005; 147:277–278.
2. D'Sa VA, High PC. Resident education in developmental pediatrics: the impact of the 80-hour work week. J Dev Behav Pediatr 2010; 31:230–232.
3. Butler JF. Use of teaching methods within the lecture format. Med Teach 1992; 14:11–25.
4. Green NL, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med 1997; 12:742–750.
5. Mickelson JJ, Kaplan WE, Macneily AE. Active learning: a resident's reflection on the impact of a student-centred curriculum. Can Urol Assoc J 2009; 3:399–402.
6. Cullen EJ, Lawless ST, Nadkarni VM, et al. Evaluation of a pediatric intensive care residency curriculum. Crit Care Med 1997; 25:1898–1903.
7. Thompson LA, Tuli SY, Saliba H, et al. Improving developmental screening in pediatric resident education. Clin Pediatr 2010; 49:737–742.
8. Gonzalez JL, Gilmer L. Obesity prevention in pediatrics: a pilot pediatric resident curriculum intervention on nutrition and obesity education and counseling. J Natl Med Assoc 2006; 98:1483–1488.
9. O’Dell JR, Peterson K, Leff R, et al. The use of outcome measures to evaluate clinical rheumatology curriculum changes. J Rheumatol 1993; 20:1033–1036.
10. Wigton RS. Effect of lectures and increased experience in gastroenterology on examination scores of internal medicine residents. Gastroenterol 1981; 80:601–604.
12. Kern DE, Thomas PA, Howard DM, et al. Curriculum Development for Medical Education. Baltimore:Johns Hopkins University Press; 1998.
13. Link TM, Marz R. Computer literacy and attitudes towards e-learning among first year medical students. BMC Med Educ 2006; 6:34.
14. Kreideweis J. Indicators of success in distance education. Comput Inform Nurs 2005; 23:68–72.
15. Kempainen RR, Hallstrand TS, Culver BH, et al. Fellows as teachers: the teacher-assistant experience during pulmonary subspecialty training. Chest 2005; 128:401–406.
16. Qualia C, Baldwin CD, Rossi TM, et al. Pediatric gastroenterology fellows, class of 2007: how well are they prepared for the future? J Pediatr Gastroenterol Nutr 2008; 47:327–333.