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Pediatric Supervisors' Point of Care Evaluation of Trainees' Procedural Readiness: A Qualitative Analysis

Friday, October 19, 2012: 2:45 PM
Room 278-280 (Morial Convention Center)
Gunjan Kamdar, MD, Pediatric Emergency Medicine, Yale New Haven Hospital, Hamden, CT, David O. Kessler, MD, MSc, Pediatrics, Columbia University Medical Center/New York Presbyterian Morgan Stanley Children's Hospital, New York, NY, Geetanjali Srivastava, MD, Pediatrics, University of Texas Southwestern Medical Center, Lindsey C. Tilt, MD, Pediatric Emergency Medicine, Columbia University Medical Center, New York, NY, Kajal Khanna, MD, Stanford University, Todd P. Chang, MD, Pediatrics, Childrens Hospital Los Angeles, Karen Owen, Yale New Haven Hospital, Dorene Balmer, PhD, Columbia University Medical Center and Marc Auerbach, MD, MSc, Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT

Purpose

Residents assume increasing autonomy in clinical practice as they progress through training.  Supervising physicians must balance resident learning with patient safety and provision of quality care.   Cate and Scheele suggested four groups of factors that influence a supervisor’s decision regarding a trainee’s readiness to perform a task independently: the trainee’s ability, the supervisor’s personality, the circumstances in which the activities are executed, and the nature of the activity. 

Our primary aim was to understand how supervising physicians assess trainee readiness to perform a procedure in the pediatric emergency department (PED).  Our secondary aims were to understand how simulation training and assessment factor into supervisor impressions and to explore supervisor transparency to parents about trainees’ experience levels.

Methods

We conducted 18 one-on-one interviews with supervising physicians and collected qualitative information regarding their assessment of trainee readiness to perform procedures in a tertiary care urban PED.  Questions were iteratively revised during the interview process.  Interviews were taped and transcribed verbatim.

We used the general inductive analysis approach to explore instructor experiences in teaching and assessing trainees.  Two researchers individually coded the transcripts and then met with a group of 4 physicians to iteratively refine codes and then create themes using qualitative software (ATLAS.ti) to augment the analysis.  The iterative process of data collection and analysis continued until theoretical saturation was achieved.

Results

Supervising physicians determined trainee readiness based on the interplay of: (a) trainee factors that include self-reported level of comfort/confidence, trainee year of training, past experiences with the trainee and, trainee’s experience with the procedure, (b) supervisor personalities, (c) the critical nature of the procedure, (d) competing clinical demands and the level of acuity in the PED, (e) the patient’s best interest and (f) parental preferences. Supervisors stated that using task-based simulators provided opportunities for practice but did not predict success on a real patient.  Although supervisors expressed belief in transparency with families about trainees’ experience level, all supervisors discussed ways they selectively omit details about a trainee’s level of experience in order to optimize experiential learning once they have determined the trainee is ready to perform.  

Conclusion

Supervisors balance various factors that determine whether the trainee is ready to perform a procedure; factors that take into account parental preferences may be unique to determining procedural readiness in pediatric populations.   Simulation allows for procedural practice, but is only one of many determinates of procedural readiness.  Supervisors value transparency, but their responsibility to trainee education compels them to selectively share information about trainee level of experience with families.