Creating a culture of lifelong learning among Med-Peds Residents

Institutional Culture is difficult to change but is imperative to the quality of physicians at an institution and its trainees. Background/Rationale Not all physicians practice life-long learning. Barriers include emphasis on clinical productivity, ineffective online searching, inadequate personal initiative and institutional culture. We were concerned that our institutional culture did not routinely stimulate the dynamic discussion of recent literature. To impact this culture, we implemented a lifelong learning lecture series for combined medicine-pediatrics (Med-Peds) physicians. Methods Articles were selected from the American Academy of Pediatrics Grand Rounds and American College of Physicians Journal Clubs. 8-10 Articles were reviewed in “rapid fire’ style and heated discussion was encouraged. Participants completed tests assessing knowledge pertaining to the articles to quantify their engagement. Results 120 articles were reviewed during 15 lectures. 37 out of a potential 40 physicians participated. Participants answered a mean of 11% more questions correctly on short term recall (p=0.0026) and on long term recall (p= 0.0600) when compared to their baseline knowledge. When comparing the questions that pertained to lectures the participants attended versus those they did not attend participants answered 7% more questions correctly on short term recall ( p=0.0800) and long term recall ( p=0.1200). Conclusions Culture is difficult to measure. The improved correct responses to questions about the papers presented suggests that the participants did engage in the discussion of the articles. Given the nature of Med-Peds training, culture change has the potential to affect the culture within both departments. O'Keefe S, Turner M, Brinn N, Newton D MedEdPublish https://doi.org/10.15694/mep.2018.0000084.1


Methods
They were selected by the first author according to their relevance to daily patient care at our institution. Summaries of 8-10 articles were individually reviewed in "rapid-fire" style. A clinical vignette was described prior to each paper and an audience response system Turning Point was used to stimulate interest in the topic and attain feedback from the audience about their current approach to such a clinical situation. After the findings of the study were revealed, an energetic discussion was encouraged to gather opinions about how the study did or did not change the status quo of institutional clinical practice. At each session the resident physicians filled out a questionnaire. The questions were true/false questions assessing knowledge regarding the outcomes of landmark articles discussed at that session. The interval between each session was usually 4-8 weeks and each questionnaire also included questions regarding the session prior to the current session -these questions were intended to represent "short term recall". In the spring of each year the residents filled out a questionnaire including all of the previous questions for the last year which was recorded as "long-term recall". Participation in the conference and the survey was voluntary. Survey responses were anonymous. The residents and faculty assigned themselves an anonymous alias so that we could track individual answers to the questions over time but this alias was not in any way linked to an identifying information that would link that individual to their survey responses. The Institutional Review Board at East Carolina University approved our study under reference number UMCIRB 12-001487.
The lecture series started in August 2012 and has continued through October 2015. In total 15 sessions were held which included one pilot session. Initially we reviewed 10 articles per session but in order to facilitate more time for the discussions between each study we decreased this to on average 8 studies per session. There was equal balance between pediatric and adult studies  . Studies reviewed were very diverse with regard to content as can be seen in Table 1  High quality medical education is determined in large part by the institutional educational culture. Clinical productivity and documentation, billing and general service provision continues to increase the time pressures on physicians. The motivation to continuously review recent literature and take the time to discuss findings with colleagues can be overwhelmed by service needs. This is especially true for institutions like ours that serve a large volume of high-acuity patients, the majority of whom are socioeconomically disadvantaged. For Med-Peds physicians the challenge is increased by the sheer volume of literature from two disciplines and perhaps decreased confidence to interpret the literature in comparison to their categorical colleagues. Culture is difficult if not impossible to measure. One encouraging outcome was that the Med-Peds physicians who attended lectures had a trend towards better knowledge of the content of the papers discussed when compared to those who did not attend the lectures and this was sustained over time.
Many residencies (including our own) usually provide formal teaching according to systems and topics. However patient care is much more haphazard and diverse than that. Our curriculum reflects the diversity of daily Med-Peds patient care which may increase enjoyment, participation and recall. Likewise lectures in residency often focus on generic review of topics, lack interactivity and are very presenter dependent. This kind of rapid-fire but case-based format focuses more on management and with the potential to impact daily clinical decision making. While we do not have any objective evidence of a change in behavior in our physicians we anecdotally did feel a palpable change in the culture. During the lectures residents and faculty alike voiced their opinions about the status quo of clinical practice and how particular papers did or did not affect their likelihood of changing their practice. Quite often the discussions about the paper would grow tangents in other directions leading to richer conversation about the evidence behind how we practice. The authors also noted both in clinic and on the wards that Med-Peds residents were including more information gained from the literature into their management plans and documentation. Other weaknesses of our study included that we failed to ensure that every participant that attended the lecture actually filled out the test questions -this could in turn result in some residents who attended the lectures being incorrectly placed in the "not present" group. However correction of this error would have made the results stronger. Also physicians were given the pre-test before the lecture but it was not picked up until the end so they could have filled out answers during the lecture. This would have resulted in some of the answers being incorrectly recorded as "baseline knowledge". Again correction of this error would have just made our results stronger. Another weakness includes the variability in the time interval between each lecture and the subsequent "short term recall" and "long term recall" questionnaires. On average the "short term recall" questions were 4-8 weeks after the lecture but this was not standardized and sometimes was longer than this. Similarly, the "long term recall" questionnaires were filled out in the spring which was more than 8 months after some of the lectures but only a few months after some of the more recent lectures. During evaluation of our curriculum we thought about possible future steps to address our overall goal of stimulating a culture of lifelong learning from the standpoint of a Med-Peds community. Discussion developed podcasts where the speakers interact together in a fun entertaining fashion while they contemporaneously review new studies relevant to their specialty and debating the relevance of the study to real world practice. 141 A similar idea could be very beneficial to Med-Peds physicians with the material directed at our practice.
We succeeded in creating a lecture series session that encouraged lifelong learning and the use of evidence based medicine by reviewing articles with high clinical impact in an interactive enjoyable fashion with our Med-Peds residents and faculty.
Mary Catherine Turner was a faculty member during the time of the study and is the current MedPeds Program director at East Carolina University Nathan Andrew Brinn was the MedPeds program director at East Carolina University at the time of the study and is currently a clinical associate professor at University South Florida. Dale Newton was a clinical professor and a associate program director of the MedPeds residency program at East Carolina University at the time of the study. He is currently retired and enjoying time with his family.