Using the Ambulatory Care Curriculum in Your Fellowship Program

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At the end of my first year of fellowship, I felt like I had completed a whirlwind tour of pulmonary and critical care medicine (PCCM). After twelve intense months spent mostly on inpatient rotations, I felt well prepared to continue to hone my skills as an inpatient pulmonary consultant and critical care physician. My comfort with and exposure to outpatient medicine, however, felt markedly different from my inpatient skill set.

As I spoke to junior faculty and mentors, I was reassured that I was not in fact alone and that it was quite common for new faculty to have a more challenging time transitioning to independent outpatient practice as compared with inpatient care. Conversations with fellows elsewhere provided additional, albeit anecdotal, evidence that the disparate PCCM fellowship training between inpatient and outpatient medicine was not unique to my program.  The perceived need for more robust ambulatory pulmonary training during fellowship seemed like something that deserved consideration and careful thought. After all, many PCCM graduates will go on to have substantive ambulatory pulmonary practices, right?

It was fortuitous that just as I started my scholarly time in fellowship back in 2014 that our then division chief, John Hansen-Flaschen, MD, and our past APD for ambulatory education, Rupal Shah, MD, were interested in creating additional ambulatory teaching for our fellowship. The rest, as they say, is history. After careful consideration to its design and the recruitment of multiple Penn pulmonary faculty to help author the first draft of the teaching scripts, the Penn Pulmonary Ambulatory Care Curriculum was born.

The Ambulatory Care Curriculum currently consists of 40 topics designed to span two academic years. The curriculum is now being reviewed and updated on an annual basis by the newly formed APCCMPD Ambulatory Care Curriculum Workgroup. We hope to continue to expand our content to include new and timely topics. For example, in this next review cycle we are working on adding content on COVID-19 vaccines and “Long COVID.”

For those who are interested in using the curriculum at their institutions, I wanted to outline some guiding principles used in its design as well as best-practices for implementation:

 

1. Accessibility

The curriculum is designed to be fellow-centric. The idea of discussion, rather than a formal lecture presentation, is meant to allow fellows to feel able to ask questions (even the “stupid” questions) in a safe space. The goal is for conversation to be inviting and open. For this reason, typically one faculty expert (rather than a room full of faculty that might unintentionally suppress fellow questions) is usually present to act as a content facilitator.

 

2. Content

The 40-topic conference syllabus is designed to be a tour of high yield, commonly encountered disease states seen in outpatient pulmonology. The topics are mapped to the ACGME milestones and the pulmonary board medical knowledge roadmap.

Each teaching script was originally authored by a member of the Penn pulmonary faculty and includes case-based discussion with literature-based answers. However, it is by no means meant to capture every management decision that might be encountered in clinic. We are continuing to evaluate curriculum content and working to add new topics while ensuring the accuracy of the existing scripts. Content will be reviewed and updated on a two-year cycle by the APCCMPD Ambulatory Care Curriculum Workgroup. We also look forward to feedback from users to help us ensure accuracy as we recognize that the literature and guidelines are ever changing.

 

3. Timing

Conferences are designed to last approximately 50-60 min and can be implemented in any order, largely based on faculty availability. The scheduling is purposefully flexible. However, in general, covering about two topics per month is recommended.

 

4. Structure

The format, as case-based discussion rather than PowerPoint-based lecture, is intentional. Flexibility often allows for less pressure to finish a PowerPoint slide deck and affords more focus on addressing what the fellows want to discuss, which will likely vary from group to group and by institution. The format may need to be adjusted slightly while some educational conferences remain virtual. In general, we suggest screen sharing a version of the script that does not immediately show the answers (but does reveal the case vignette, questions, relevant tables and figures) and then distributing the full script with answers to your trainees after. However, we recognize that something different may work better for different faculty and trainees, so feel free to adapt as you see fit.

 

5. Flexibility

Depending on the nature of the discussion, it is fine if you do not get through all of the content in a given session, as the priority will be answering fellows questions. Complete copies of the conference teaching script can always be distributed after the session.

 

6. Target Learners

The content is designed to be a review for fellows of all levels. Personally, I often referenced these guides as a new attending as I got my feet wet in clinic.

 

7. Evidence for Use

An initial pilot study of the curriculum at Penn showed us that our fellows found the curriculum to be a needed addition to their ambulatory education. A subsequent multi-institution study funded through the APCCMPD medical education grant assessed the current state of ambulatory training in PCCM fellowship as well as the curriculum’s impact on fellows’ ambulatory knowledge and competency

In total, 19 programs from regions across the country participated in this study between 2017-2019.  Six programs received the first year of content, seven received the entire 2-year curriculum and seven programs served as a control. Fellows, faculty and program directors (PDs) completed a series of surveys assessing satisfaction with ambulatory education and the curriculum. Fellows completed a series of medical knowledge inventories and programs submitted in-training exam scores.

Before curriculum implementation, only 34.4% of fellows rated the quality of their ambulatory education as good or outstanding compared with 57.9% at the end of the study. Eighty-five percent of faculty and 89% of PDs rated the curriculum as good or excellent. Faculty felt the teaching scripts were easy to use (78.4%), factually accurate (86.3%) and provided high-yield information (82.1%). The majority of PDs indicated that the curriculum positively impacted patient care (78%), fulfilled an unmet educational need (100%), and planned to continue the curriculum after the study (78%). Unfortunately response rates to the knowledge inventories were too low to make definitive conclusions about impact on medical knowledge. Feedback surrounded the need for updated content based on recently published guidelines and studies.

Based on our study, the curriculum is a standardized and feasible way to address a previously unmet need in PCCM fellowship education. PDs rated the curriculum highly and most plan to continue it in the future. Our limited data set suggests that the curriculum was well received by fellows and faculty and positively impacted perceptions of ambulatory education and preparedness for independent practice.

 

With the assistance of the members of the APCCMPD Ambulatory Care Curriculum Workgroup, we are excited to offer this peer-reviewed and updated curriculum to training programs across the country. We hope that you find this curriculum to be a meaningful addition to your training programs and look forward to hearing your feedback!

 

Stacey Kassutto, MD is an Assistant Professor of Clinical Medicine in Pulmonary and Critical Care at the Perelman School of Medicine at the University of Pennsylvania. She completed all of her medical training, including PCCM fellowship and a fellowship in medical education, at Penn. She currently serves as the Associate Director of the Medical Education Track, Director of Simulation Education for the Internal Medicine Residency, and is core faculty for the PCCM Fellowship (and recent past Associate Program Director for Ambulatory Education) at Penn. In addition to serving as the Chair of the APCCMPD Ambulatory Curriculum Committee, she is also a member of the ATS Section of Medical Education Executive Board.

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