PubMed1997
OBJECTIVE: To teach residents to recognize and treat critically ill or injured infants, children, and adolescents in a 1-month, intensivist-designed, second-year resident pediatric intensive care rotation curriculum while maintaining optimal patient care and resident educational satisfaction. DESIGN: Descriptive evaluation of an intensivist-designed, second-year resident pediatric intensive care rotation curriculum from September 1994 to May 1996. SETTING: Multispecialty 16-bed pediatric intensive care unit (ICU) staffed by five pediatric critical care physicians in a university-affiliated children's hospital supporting a pediatric residency program. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our second-year resident pediatric ICU rotation curriculum consisted of direct patient care, participation in clinical rounds under the supervision of a pediatric critical care attending physician, and a 1-month formal curriculum. A standardized test evaluated resident pediatric critical care knowledge before and after the pediatric ICU rotation. Number and type of resident procedures were documented. Four-point Likert scale questionnaires were used to evaluate resident educational satisfaction and resident performance. Opportunity cost, the graduate medical education return on educational investment, the critical care attending physician's return on resident investment, and the optimal teaching time for number of rotation residents were calculated. Unit demographics were documented. Data analysis included multivariate analysis, t-test, and chi-squared techniques. Significance was defined as p < .05, rotated factor loading > 0.5, and Eigenvalues > or = 1. Kmeans identified clusters. From September 1994 to May 1996, 71 residents, 34 (48%) from pediatric or medicine-pediatric programs and 37 (52%) from emergency medicine residency programs, participated in our second-year pediatric ICU resident educational process. All residents showed improvement between pretest and posttest knowledge scores (p < .05). Seventy percent of the variance in critical care attending physician evaluations of the residents during their pediatric ICU rotation was based on bedside clinical skills (31%), communication skills (20%), and basic knowledge base (19%). Critical care attending physician evaluations of residents placed residents into three clusters: "hands-on," "well-rounded," or "book-heavy" residents. Prerotation test scores, postrotation test scores, and numbers of procedures performed did not correlate with how critical care attending physicians evaluated overall performances of individual residents. Three factors explained 61% of the variances in resident satisfaction with the pediatric ICU rotation: clinical experience (27%), formal didactics (18%), and text availability (16%). Resident educational satisfaction did not appear to depend on access to procedures. Critical care attending physicians spent a minimum of 12.6 hrs/wk involved in resident education. The opportunity cost for using critical care attending physicians to provide 12.6 resident teaching hours per week was calculated as $111,384/yr. Pediatric ICU patient demographics, morbidity, and mortality did not change during the introduction of the resident educational program in the pediatric ICU. CONCLUSIONS: During a required pediatric ICU resident rotation, balancing the resident's educational and decision-making autonomy needs and the critical care attending physician's desire to provide consistent bedside care of the critically ill child is an ongoing interactive process that requires substantial personnel, time, and financial commitments. It is possible to maintain patient care in the pediatric ICU and provide residents with a satisfying pediatric ICU experience. Trends in financial reimbursement may limit our present time commitment to the resident pediatric ICU curriculum.