Continuity Clinic Perspective Faculty Perspective Fellow Perspective Resident Perspective

Implementation: Faculty Perspective

As we completed the first phase of case writing for the Bright Futures curricula and initiated the pilot testing of the curricula, we set for ourselves three main goals:

1) To integrate Bright Futures principles into the primary care training of pediatric residents
2) To provide a longitudinal component to resident education about growth, development and behavior, and adolescent medicine, and
3) To enhance resident teaching skills by providing training and experience in the case-discussion method.

Our first step was to choose a site within our own institution to pilot test our curriculum. We chose the context of the residents’ continuity clinic for several reasons. The majority of training in primary care and normal growth and development occurs in continuity clinic, and a format of resident taught pre-clinic conferences already existed with an established curriculum committee and schedule of topics to be covered on a yearly basis. We felt our curriculum, based on Bright Futures principles, complimented the existing continuity clinic format.

The assignments of dates to pilot test cases from our curriculum were based on readiness of case materials and needs identified by specialty faculty and the curriculum committee, which consisted of both faculty and residents. Topics were assigned for 5 consecutive sessions within a week and residents from each clinic day signed up to teach specific topics. The week before the topic was scheduled to be taught, faculty from our project met with the resident teachers for a training session. The faculty reviewed the specific materials for the case, including case description, teaching guide, references and evaluation forms. In addition, the faculty member discussed principles of case-based teaching and modeled how to facilitate the particular case discussion with the prospective resident teachers. A member of our project was also one of the preceptors within the continuity clinic itself. This greatly facilitated the integration of our standardized cases into the established curriculum and the acceptance of our materials and the case-based approach.

Limited time was a significant challenge throughout the implementation process. The resident teachers had clinical conflicts that sometimes precluded their attendance at training sessions or meant that they could attend part of the session only. This challenge was initially addressed by conducting more than one training session. However, that strategy became too demanding of faculty time. During the course of the implementation phase, the continuity conference time was shortened from 60 to 45 minutes. This left little more than 30 minutes for actual discussion of cases presenting a greater than anticipated challenge to the resident teachers. We addressed this by prioritizing learning goals during the training session and offering alternative formats.

At times, the learning goals identified by the continuity clinic faculty differed from the goals our project. Some clinic faculty felt that the variability in case discussion from day to day introduced the risk that important information might not be covered. We addressed this concern by developing handouts that summarized all salient information on a given topic as well as a list of suggested readings. Resident teachers were instructed to review the main points of the discussion at the end of each session and faculty had the opportunity to augment this summary with comments of their own.

Initially, residents and clinic faculty needed time to adjust to the transition from a teaching culture of traditional lecture to one of case-based discussion. At times, continuity clinic faculty participation unintentionally compromised the role of the teaching resident. For example, it was challenging for the resident teacher to be recognized as the discussion leader when a faculty “expert” made running comments. This was addressed by giving specific feedback to the clinic faculty as well as providing the residents with strategies for dealing with the situation during the training session. At first, residents needed more specific guidance in how to lead a case discussion. However, over time, residents and faculty became more comfortable with the case discussion method and less modeling was needed.

What we learned:

1. Writing good cases takes much time and dedicated authors.
2. Resident teachers need specific coaching in facilitating case discussion as well as orientation to the teaching materials for a specific case ahead of time.
3. Continuity clinic faculty members need to facilitate residents’ teaching roles and be aware of the impact of their participation in the discussion.
4. Identifying goals and learning needs of clinic faculty and residents can help in developing cases that enhance the overall curriculum and are accepted by the intended audience of learners.
5. Having a member of our project among the continuity faculty greatly facilitated incorporation of the new curriculum into the clinic curriculum.
6. Providing all materials in organized format to resident teachers greatly facilitated use of materials in teaching session. Support staff was needed to photocopy materials and collect evaluation forms.
7. Case teaching session should not be scheduled for less than one full hour. When this is not possible, cases may best be taught in two successive weekly sessions.

Enthusiasm of faculty for learner centered curricula is infectious and critical to success of incorporating Bright Futures Health Supervision Guidelines into health care for children and adolescents.
Carolyn Frazer, M.D.