Michelson Catherine D, Dzara Kristina, Ramani Subha, Vinci Robert, Schumacher Daniel
a Department of Pediatrics , Boston University School of Medicine , Boston , Massachusetts , USA.
b Department of Pediatrics , Massachusetts General Hospital for Children , Boston , Massachusetts , USA.
Teach Learn Med. 2019 Jan-Mar;31(1):99-108. doi: 10.1080/10401334.2018.1478732. Epub 2018 Oct 10.
Residency training in many specialties has traditionally been divided into short, discrete, single-specialty rotations. Although providing the learner with in-depth exposure to a specific discipline, educators have challenged this rotational model, citing problems with patient and team continuity and maladaptive coping. Longitudinal integrated clerkships, adopted by many medical schools, offer an alternative model and have demonstrated improved outcomes for students related to patient-centeredness, advocacy, and integration with teams. Despite this, longitudinal integrated training in residency is rare.
We developed a novel 3-month longitudinal integrated block for residents, called Keystone. The block combined 3 previously discrete, shorter rotations in developmental-behavioral pediatrics, advocacy, and emergency medicine into a longer and integrated experience. Within each week, the block utilized half-day sessions in the resident's primary care clinic, a new continuity Developmental Behavioral Pediatrics clinic where the resident worked with the same faculty preceptor and interprofessional team each week, shifts in the emergency department, and half-day sessions dedicated to clinic- and community-based advocacy activities.
The context was a single, large pediatric urban residency program based at 2 university-affiliated hospitals, an academic freestanding children's hospital, and academic safety net hospital.
Using a phenomenologic framework, we conducted interviews and a focus group discussion to explore residents' attitudes about the block; their perceptions regarding the block's impact on relationships with preceptors, peers, or patients; and the block's impact on learning and practice. Fourteen residents participated, 10 in interviews and 4 in the focus group discussion. Six themes emerged from thematic analysis: (a) the longitudinal nature of Keystone influenced professional relationships and as a result entrustment, (b) the longitudinal integrated design shaped engagement and learning, (c) flexibility promoted work-life balance and self-directed learning, (d) learners experienced time and space for professional identity development, (e) Keystone provided a unique opportunity to reclaim patient-centeredness, and (f) learners experienced important advantages and challenges related to the schedule.
The longitudinal integrated nature of Keystone provided a novel structure for addressing important yet challenging educational goals in residency, including enhancing relationships, facilitating entrustment and engagement, encouraging patient-centeredness, and emphasizing the importance of self-directed learning.
传统上，许多专业的住院医师培训被分为短期、离散的单一专业轮转。尽管这种轮转模式能让学习者深入接触特定学科，但教育工作者对其提出了质疑，指出存在患者和团队连续性问题以及适应不良的应对方式。许多医学院采用的纵向整合见习提供了一种替代模式，并已证明在以患者为中心、倡导以及与团队整合方面，学生取得了更好的成果。尽管如此，住院医师阶段的纵向整合培训却很少见。
我们为住院医师开发了一个为期3个月的新颖纵向整合模块，名为“基石”。该模块将发育行为儿科学、倡导以及急诊医学这3个之前离散的较短轮转整合为一个更长的综合体验。在每周内，该模块在住院医师的初级保健诊所安排半天课程，在一个新的连续性发育行为儿科学诊所，住院医师每周与同一位带教教师和跨专业团队合作，在急诊科轮班，并安排半天课程专门用于基于诊所和社区的倡导活动。
背景是一个大型的城市儿科住院医师项目，设在两家大学附属医院、一家独立的学术儿童医院以及一家学术安全网医院。
我们使用现象学框架进行访谈和焦点小组讨论，以探讨住院医师对该模块的态度；他们对该模块对与带教教师、同行或患者关系的影响的看法；以及该模块对学习和实践的影响。14名住院医师参与，10人接受访谈，4人参加焦点小组讨论。主题分析得出了6个主题：(a) “基石”的纵向性质影响了专业关系，进而影响了信任；(b) 纵向整合设计塑造了参与度和学习；(c) 灵活性促进了工作与生活的平衡以及自主学习；(d) 学习者有时间和空间进行职业身份发展；(e) “基石”提供了一个回归以患者为中心的独特机会；(f) 学习者在日程安排方面体验到了重要的优势和挑战。
“基石”的纵向整合性质为解决住院医师培训中重要但具有挑战性的教育目标提供了一种新颖的结构，包括加强人际关系、促进信任和参与度、鼓励以患者为中心以及强调自主学习的重要性。
