Ambulatory Curriculum Enhancing Education for Modern Resident Learners

The Accreditation Council for Graduate Medical Education (ACGME) acknowledges the requirement for formal outpatient resident education with recent shifts toward increasing ambulatory hours; however, clear and uniform guidelines for implementing these curricula are not emphasized.¹ Although the majority of graduates choose primary care, residency education has limited emphasis on formal ambulatory education.² Gaps in medical knowledge of common ambulatory topics in pediatrics and internal medicine exist, leaving residents feeling better-equipped to practice inpatient medicine.^3,4 Furthermore, limited outpatient education can deter residents from choosing outpatient careers.⁵

Ambulatory education reform is vital for improving knowledge gaps in residency training. Ambulatory curricula are often found to be impractical for residents and challenging for preceptors, so many residents do not fully engage in all components of published curricula.^6,7 In addition, current learners, coined “Generation Z,” have unique learning styles; they are independent, technologically driven learners who prefer brief, visually stimulating topics as opposed to traditional lectures. Adult learning theory emphasizes the need to consider generational diversity when tailoring medical curricula.^8-12 To address some of these current gaps and limitations, we created a novel, structured, longitudinal pediatric ambulatory curriculum geared toward closing the curricula gap, while providing standardization of ambulatory education and increasing resident knowledge, satisfaction, and practical application. This strategy can be adopted by other primary care programs to improve outpatient residency education.

The Staten Island University Hospital pediatric residency program consists of 24 residents (eight residents per postgraduate year [PGY] class), who attend weekly continuity clinics. The curriculum initially was created to be completed over 12 months and to be repeated annually. Topics were chosen from high-yield pediatric board exam content, common clinical scenarios, and subject areas of previous in-training exams on which residents underperformed. A new topic was scheduled weekly. The clinic preceptors facilitated the small group teaching sessions on the assigned topic with the ambulatory trainees who were scheduled during each clinic session. No prework was assigned. The duration of each teaching session was 10 to 15 minutes, including one- to two-page topic guides prepared by faculty and three to five questions given as pre- and posttests. The planned 12-month curriculum was paused after 9 months due to the pandemic; feedback from residents and faculty was then incorporated, resulting in a revised curriculum following an 18-month structure. With an 18-month curriculum, each topic would be presented twice during each resident’s 3-year training.

The initial curriculum was split into two parts (A and B, with Part B resuming after the pause). A cumulative exam was administered at the end of Parts A and B to objectively assess knowledge retention. Residents who completed Part A also completed a 1-year follow-up exam after completion of the curriculum to assess long-term knowledge retention. We used a Likert scale from 1 to 5 (1=not at all, 5=very much) to assess resident satisfaction scores, increase in knowledge, and use of the curriculum in clinical practice.

We described continuous variables by mean and standard deviations, and summarized categorical data as frequency counts and percentages. We used a paired t test to compare continuous variables between pre- and postintervention. We used the analysis of variance method to compare mean differences between PGYs. All statistical tests were two-sided. P values less than .05 were considered significant. All statistical analyses were performed using SAS version 9.4 (Statistical Analysis Systems Inc). The project was submitted for human subject research determination review and was determined to be exempt from review by the institutional review board.

Thirty-two residents were exposed to the curriculum; 16 participated in both parts of the curriculum (A and B). We noted increases in knowledge with the implementation of the new curriculum. Figure 1 demonstrates cumulative mean test scores for the weekly pre- and posttests, final exam, and 1-year follow-up exam. Mean posttest scores significantly increased compared to pretest scores for Parts A and B and the overall combined curriculum. Mean final exam scores significantly increased compared to pretest scores, indicating sustained knowledge. The 1-year follow-up mean exam scores for Part A were sustained from the mean final exam scores, demonstrating longitudinal knowledge retention. Although mean follow-up exam scores decreased compared to mean weekly posttest scores, we found statistically significant increases compared to the pretest, demonstrating overall knowledge increase.

Figure 2 displays mean pretest, posttest, and final exam scores for the combined curriculum by postgraduate year. We noted improvements in pretest to final exam mean scores from PGY-1 to PGY-2 and stronger statistically significant increases from PGY-1 to PGY-3. All three groups showed an increase in knowledge scores from pretest to posttest and follow-up exam, with more experienced residents having higher baseline knowledge scores.

Regarding resident feedback on the curriculum, mean scores (+/– standard deviation) for curriculum efficacy, self-reported increase in knowledge, and overall satisfaction ratings were 4.5 (+/– 0.8), 4.6 (+/– 0.5), and 4.6 (+/– 0.5) out of 5, respectively. When asked whether the knowledge gained from the curriculum was being used in clinical practice, the mean score was 4.45 (+/– 0.6) out of 5. When asked whether the residents planned to use (or continue using) the knowledge gained from the curriculum in clinical practice, the mean response was 4.73 (+/– 0.6) out of 5.

Ambulatory education reform in residency is an understudied yet fundamental area for improving knowledge gaps in residency training. While some residency programs use extramural curricula, they are often found to be impractical for residents and challenging for preceptors, so many residents do not fully engage in all components of published curricula.^6,7 The majority of residents do not complete prework due to time restraints and lack of extrinsic motivators, with one study noting 51% of residents did not even open their emails or access the curriculum materials, and only 37% completed the prework.⁷

We integrated a teaching model that adapted well within busy ambulatory clinics. Generation Z learners have unique learning styles, and adult learning theory emphasizes the need to consider generational diversity when tailoring medical curricula.^8-10 Those in Generation Z are independent, technologically driven learners who prefer brief, visually stimulating topics as opposed to traditional didactics and lectures.^10-12 We kept teaching points brief and succinct, incorporating short bursts of teaching on practical pediatric topics in small group environments compared to lengthier, in-depth topics that may limit retention. This format targets modern learners and minimizes interruptions to clinic flow and patient care. Adult learning is effective when learners provide input during the process.⁸ We used resident feedback to tailor the curriculum to the learners’ educational needs.

Our data demonstrated that implementation of a formal ambulatory curriculum geared toward modern pediatric learners improved resident knowledge and increased satisfaction with ambulatory education. Our curriculum provided a standardized outpatient education with consistent topics in a high-yield learning format with easily accessible resources for self-study without relying on prework completion prior to sessions. This specific curriculum and resources can be used by pediatric and family medicine training programs to enhance teaching of pediatric ambulatory topics. The curriculum model can be implemented on a broader scale; it is not only applicable to pediatric and family medicine programs, but also to other disciplines across different institutions to improve resident knowledge and enhance patient care with minimal interruption to the clinical session.

In conclusion, this curriculum was feasible, well-liked by learners, and led to increased knowledge for participants. Generalizability may be limited by the study’s single institution nature and implementation into a small pediatric residency program. Additionally, while attempts were made to standardize teaching with consistent material, sessions were taught by different faculty members, which may have influenced their efficacy and satisfaction scores. Furthermore, not all participants completed the full curriculum. While residents reported using the curriculum in clinical practice, the impact on patient care was not assessed. Finally, a control group of learners who were not exposed to the curriculum was not included in this study; therefore we are not able to determine how much of the improvement in longitudinal testing scores was due to the education provided in the curriculum versus expected increases in knowledge over time for trainees. Future directions include assessing resident behavior changes and effect on direct patient care with chart reviews, direct observations, and patient feedback.