Baylor College of Medicine
Houston, TX

Program Description
The Pediatric Pulmonology Fellowship Program at Baylor College of Medicine prepares its graduates to have successful careers in academic, private, and community settings. The program provides a wide range of learning opportunities in both common and rare pediatric pulmonary diseases. The program accepts three fellows per year making it one of the largest pediatric pulmonology programs in the US. Fellows develop strong clinical, teaching, and research abilities while also meeting the requirements for subspecialty certification.

Type of Program
Pediatric Pulmonary

Number of Fellows in Program
9

Abstract authors
Jennifer A. Rama, MD, Julia B. Lawrence, RT, Bradley Cross, RT, Miesha Hughes, RT, Lisa Traplena, RT, Marc G. Schecter, MD

Submitter(s) of Abstract
Jennifer A. Rama, MD

BACKGROUND
Fellowship programs should prepare learners to be able to practice in different types of settings, including ones with limited ancillary support. Many pediatric pulmonologists rely heavily on the skills of respiratory therapists (RT), leaving pulmonology fellows less equipped to practice in smaller, community-based outpatient clinics where an RT may not be available. Learners in tertiary care academic centers are particularly vulnerable to receiving less hands-on experience due to widely available resources and staff. Thus, pulmonary trainees should demonstrate competency in basic RT skills in order to treat patients with pulmonary diseases successfully.

GOALS
1. Enhance skills and knowledge in:
     a) Oxygen delivery devices,
     b) Spirometry,
     c) Metered dose inhalers (MDI) and
     d) Airway clearance devices.
2. Demonstrate competency in skills that will enable a pediatric pulmonologist to practice independent of an RT in an outpatient setting.

METHODS
A needs assessment survey was sent to incoming and current pediatric pulmonology fellows to determine which RT skills were most necessary to teach and evaluate. The curriculum content was designed based on needs assessment results and focused on airway clearance devices with an additional written exam on airway clearance principles. Instruction was provided according to pre-defined objectives and included didactic and hands-on tutorials. Four general skills were evaluated before and after instruction; 1) providing airway clearance instruction 2) providing MDI instruction 3) selection/connection of oxygen delivery devices and 4) obtaining acceptable spirometry. Fellows performed skills under direct observation of fellowship program leadership and experienced RTs. Checklists of critical items necessary to perform the skill proficiently was completed. Data was analyzed using Mcnemar’s test and Wilcoxon matched pair test. At the conclusion of the course, fellows were asked to complete individual tutorial and overall course evaluations to collect feedback and to determine whether the goals and objectives of the curriculum were met.

RESULTS
The response rate of the needs assessment was 75%. Data revealed a perceived knowledge gap particularly in airway clearance devices and to a lesser extent in aerosolized medication, oxygen delivery, and spirometry. Nine fellows with varying levels of training from first to third year fellowship participated in the curriculum, but only six or seven fellows were included in the analysis depending on the skill station completed. Fellows who did not complete both pre and post assessments were excluded. There was a significant improvement in the medians of written test scores and the percent items performed correctly during instruction of mask and mouthpiece spacers with MDI, acapella, flutter, and threshold positive expiratory pressure device, p<0.05, n= 7. Data from completed individual tutorial evaluations, n=6, revealed a significant self-reported improvement in selection of appropriate oxygen delivery devices, differentiation of oxygen interfaces and flow, as well as in coaching patients to perform spirometry according to American Thoracic Society acceptability criteria, p<0.05. Data from completed overall course evaluations, n=6, revealed that the course objectives had been met; one hundred percent of fellows felt that they improved their skills and acquired knowledge in all four areas. Furthermore, all fellows indicated that the curriculum should be offered yearly.

CONCLUSION
This novel and interactive curriculum provides meaningful competency-based assessment of pulmonary trainees in RT skills essential to treat pediatric patients with pulmonary disease. By evaluating fellows’ ability to provide instruction to others, the curriculum incorporates the learning pyramid theory which illustrates the best educational method to enhance the most retention is through teaching. Future directions include determining retention time of skills and knowledge acquired from this learning experience.