June 2020

What was the problem in question?  Greater competition in the NMRP Match has led to a “Match Frenzy” in which pediatric residency applicants are applying to and ranking an increasing number of residency programs.    How was the problem addressed?  A residency advising committee composed of school of medicine faculty and local residency program directors worked with students to create individualized application plans. The committee used data from the AAMC Apply Smart and NMRP Charting Outcomes in the Match to create 5 tiers of student competitiveness ranging from “at-risk candidate” to “highly competitive candidate.” USMLE Step 1 scores and clerkship grades were used to determine competitiveness, as 95% of residency programs use Step 1 scores to select candidates for interviews and 40% set a target Step 1 score. For each tier of student competitiveness, the committee recommended that applicants apply to a given number of programs with a specific distribution of program quality. To determine program quality, the committee compiled a list of programs and classified them into one of four categories ranging from “mostly solid” to “top caliber” based on information from the AMA’s Fellowship and Residency Electronic Interactive Database Access, US News and World Report rankings, and local expert opinion. In one-on-one meetings with students, committee members encouraged the most competitive students to apply to fewer programs. For “at-risk” students, the committee provided multiple counseling meetings and additional support throughout the application cycle.     The authors report success with this program. Over the past 3 years, students at their institution have applied to a mean of 26.6 pediatric residency programs compared to a national average of 37.9 in 2019. Additionally, more than half of students applied to fewer than 25 programs.     What are the implications of this report?  Using an individualized approach to application counseling, the institution was able to reduce the number of programs that pediatric residency applicants applied to. Faculty may be able to incorporate similar proactive and individualized counseling initiatives at their institutions. Further research is needed to determine if this approach can be successfully scaled up and applied to diverse institutional settings, and how the process of counseling students may change when the USMLE Step 1 transitions to pass/fail score reporting.

Editor’s note: This paper is more of a description than a study. It reports a well thought out program at the Nationwide Children’s Hospital in Columbus, Ohio. Clerkship and residency faculty guide students in the development of an individualized application plan for applicants to pediatric residency programs. As acknowledged, the approach advocated is not unique to that institution, but the program, as outlined, is data based, systematic, and successful as judged by a reduction in the number of programs candidates apply to saving wear and tear and money for both programs and applicants. This paper was submitted to Academic Pediatrics in mid-February. I am curious about the impact of covid-19 on all aspects of the residency application and match process. (RR)

Leeds FS, Atwa KM, Cook AM, Conway KA & Crawford TN. Medical Education Online (2020); 25:1,DOI:10.1080/10872981.2020.1742967

Reviewed by: Carly Blatt & Amit Pahwa

What was the study question?  Does teaching specific metamemory techniques (MMTs) improve medical students’ ability to generate differential diagnoses?

How was the study done?  A crossover control design was implemented during a Family Medicine Clerkship where 114 students participated in a differential diagnosis workshop. Students were given a “pre-case” and generated a differential diagnosis; they were then taught a specific MMT and given a different “post-case” to generate a differential diagnosis. This process was repeated with four separate MMTs (Constellations, Mental CT Scan, VINDICATES, and Bundling). A crossover design was used to limit bias from completing the same case twice. The absolute number of diagnoses in each case was collected. The lists were screened to remove clinically unlikely diagnoses. The difference between the number of diagnoses in each set of pre- and post-MMT teaching cases was calculated. A post-workshop survey gathered information regarding the perceived effectiveness of each MMT.

What were the results?  For both unscreened and screened differential diagnoses lists there was a statistically significant difference between the number of diagnoses when all MMTs were taken into account with an increase in number of diagnoses by 2.27 and 2.04 respectively. However, only the Mental CT scan was independently statistically significant. This corresponds with the post-workshop survey in which students perceived the Mental CT Scan to be most useful.

What are the implications?  Methods for generating differentials are not equivalent. This study demonstrates a possible synergy to using MMTs concurrently. However, if one method is chosen, the Mental CT scan method may be the best.  While students may improve their differential diagnosis list length, it is unclear how this would translate clinically.

Editor’s Comments: This interesting study explores the generation aspect of development of a differential diagnosis - whereby the learner generates a “robust candidate list of diagnoses.” It does not, however, address the subsequent steps of filtration (removing diagnoses that do not fit) and ordering or prioritizing the diagnoses. I can’t help but feel cautious with these results that  focus on the number of diagnoses rather than the latter two steps which personally I find more often to be difficult steps in diagnostic reasoning for students (KFo).

Huth K, Audcent T, Long-Gagne S, Dbrocchi AM, Weiser N, Miller D, Arje D, Stephens D, Major Nathalie, Issa K, Cohen E, Orkin J. Academic Pediatrics 2020. doi: 10.1016/j.acap.2019.09.002

Reviewed by Julia Donner

What was the study question?  Does a standardized complex care curriculum improve pediatric residents’ capacity to care for children with medical complexity (CMC)?

How was the study done? This was a mixed-methods study among pediatric residents of all training levels. First, a randomized control trial of a standardized curriculum was conducted. Residents were randomly assigned to take part in either the intervention group which consisted of interactive modules on complex care topics including clinical assessment, care planning, and technological dependency or a control group which consisted of modules on noncomplex care topics. The primary outcome was the post-intervention mean score on an OSCE of tracheostomy care. Second, semi-structured post-intervention interviews were conducted to gather qualitative data to assess the secondary outcome: resident self-efficacy in caring for CMC.

What were the results?  Two months after participation in the study, there was no significant difference in mean OSCE score between intervention and control groups, indicating no improvement in practical skills following participation in the standardized curriculum. However, at baseline, only 9% of studied residents felt comfortable caring for CMC. Following the intervention, resident feedback revealed increased comfort in caring for CMC as well as an overall better understanding for complex care training. Qualitative result analysis identified both educational gaps related to CMC, potentially useful for residency curriculum development, as well as beneficial skills gained such as learning about limitations of care and practicing in the face of uncertainty. Residents identified caring for CMC as an important part of their professional identity as a future pediatrician.

What are the implications of these findings?  This study highlighted ongoing training needs for pediatric residents in the realm of complex medical care. Standardized curricular modules appear to be an appropriate tool to increase resident understanding of complex care needs in Pediatrics, however, they are not sufficient for complete training. Based on qualitative responses from residents, practical, integrated, and multidisciplinary exposure is necessary to increase technical and procedural skill and overall comfort in the care of CMC.

Editor’s note: Caring for Children with Medical Complexity can be daunting, especially for less experienced practitioners like medical students and residents. Even though the pediatric residents did not demonstrate improvement in practical skills taking care of CMC as measured by an OSCE, the demonstration of increased comfort and overall understanding of CMC is a very positive outcome setting the stage for improvement in clinical skills with practice. A curriculum that can promote that outcome would be quite useful for training pediatric residents and even more experienced caregivers called upon to provide medical care for CMC. (RR)