Harbor – University of California Los Angeles Medical Center
Torrance, CA

Richard Mink, MD, MACM

To provide an exceptional clinical experience, the harbor-UCLA Pediatric Critical Care Medicine fellowship utilizes clinical rotations at two uniquely different sites, Harbor-UCLA Medical Center, a Los Angeles County facility and CHOC Children’s, a freestanding children’s hospital. These two institutions are highly complementary, both in patient population and administrative structure, and this confers a significant benefit in terms of experience. By rotating through these pediatric intensive care units (PICUs), fellows interact with numerous pediatric intensivists as well as multiple pediatric subspecialists. By the end of their training, fellows are well prepared to practice pediatric critical care medicine in a variety of settings.

Although we feel we provide an excellent clinical training environment, it is the innovative curricula of which we are most proud. These were developed to teach all six competencies which we believe one must excel in order to be an outstanding physician. Our curricula are highly interactive, usually case-based and are often supplemented by short (10-15 minutes) didactics to provide background information or data. 

In the professionalism, cultural competency and bioethics curriculum, the first session begins with a clip of “house” to foster discussion about “what is professionalism.” in pairs, fellows apply the concepts to different scenarios related to disclosure of medical errors, impairment of peers and societal obligations. To teach conflict of interest, an audience response system (ARS) is used to poll fellows as to what pharmaceutical gifts they believe are appropriate. Then, data showing the influence of these gifts are presented and discussed, ending with a review of the institutional policy for conflict of interest. Prior to the session on conflict management, fellows complete the Thomas-Kilmann Conflict Mode instrument. A =CU scenario is subsequently analyzed in which the fellows determine whether their preferred mode for conflict resolution was appropriate for that particular situation. The importance of maintenance of certification is explored using facilitated discussion so that there is a full understanding of the physician’s obligation to society. Sessions on bias and stereotyping and healthcare disparities focus on how these influence patient care in the PICU, particularly related to end-of-life decisions and language barriers. These utilize illustrative cases and viewing and discussion of the PBS trailer of “Unnatural Causes…is inequality Making Us Sick?” The three sessions on bioethics use pre-session reading, ARS and small group discussion to learn how to apply the principles of bioethics and to understand the legal aspects of common ethical issues in the PICU.

To improve communication, fellows view videos demonstrating inappropriate and appropriate approaches to provide bad news to parents followed by discussion about what they observed. Based on a specific case, each fellow is then videotaped giving bad news to an actor playing the role of a parent. This is shown to the faculty and other fellows so that constructive comments can be provided to improve the fellow’s skills. In another effort to improve communication, each fellow is required to read “Difficult Conversations” and then write a self-reflection explaining how he/she can incorporate the main points of the book into practice.

Each fellow conducts morbidity and mortality reviews and completes a quality improvement project. M and M’s are structured and focus not only on patient care but also review whether communication among services and with the family was satisfactory and whether chart documentation was sufficient. The quality improvement project is accompanied by required readings and web-based modules followed by a written test to assure compliance.

A leadership curriculum was created to provide the fellows with the necessary skills to develop into leaders. Each fellow first completes a Myers-Briggs Type indicator to begin to understand their own personality traits. Fellows then read “classic” books about self-assessment, emotional intelligence, instituting change and team building. After each reading, fellows write a self-reflection describing the main points of the book and how they plan to utilize them. This is followed by conferences in which each book is discussed.

Throughout the program, there is instruction in teaching the fellows “how to teach.” Sessions are held about how to provide bedside teaching, specific classroom teaching techniques, curriculum development and assessment of outcomes. There are workshops to educate about writing goals and objectives, making PowerPoint slides and creating polling questions for ARS. Interaction with the audience and innovation are highly encouraged and direct feedback to the fellow is provided after every session.

These curricula were developed to maximize learning by fully engaging the trainee. our goal is to train pediatric intensivists who are excellent clinicians, fully understand what it takes to be an outstanding doctor and have the tools necessary to become leaders in the field of pediatric critical care medicine.