Improving Procedure Skills in PHM Fellowships: A Stepwise Strategy

Procedural experience has been an ongoing challenge in pediatric graduate medical education due to decreasing clinical procedure opportunities.1 Many pediatric residency graduates report never achieving competency in the Accreditation Council on Graduate Medical Education (ACGME)–required procedures.2 This deficit in training is likely to worsen as the requirements for competency in procedures have narrowed with the revised ACGME pediatric residency requirements effective July 2025. Recent accreditation standards for Pediatric Hospital Medicine (PHM) fellowships identify a list of procedures in which fellows are to demonstrate competency. Procedures required by both program types include bag-mask ventilation, lumbar puncture, neonatal delivery room stabilization, and peripheral intravenous catheter placement. Residents must also be able to perform simple laceration repair.3 Furthermore, fellows are required to demonstrate their skills at arterial puncture; bladder catheterization; intubation; (re)placement of nasogastric, orogastric, and gastrostomy tubes; establishing intraosseous access; procedural sedation; and tracheostomy tube replacement.4 Procedures are the most common clinical skill in which PHM fellows report inadequate training.5 Many hospitalists, often related to their practice contexts, currently do not attempt the majority of these procedures in their practice, particularly as more procedures are performed by subspecialists, nurses, and other health professionals.6 PHM fellowship graduates acknowledge low levels of confidence and perception of inadequacy for teaching procedures, which is likely a reflection of the lack of procedural exposure they have received throughout their training, as well as the limited number of suitable faculty and curricula.7 Residency graduates entering PHM fellowships will have an even greater need for procedure training in fellowship given the aforementioned changes to residency requirements. This need solidifies procedures as part of our field’s identity and responsibility. This incongruence between expectations of procedure competency and real-world practice prompted our group to reconsider existing procedure training strategies in our field.Simulation is a mainstay of procedure education because it helps learners develop skills that are infrequently utilized in clinical practice.8,9 Simulation using task trainers helps establish and maintain procedural competency. Simulation is the next best option to direct observation in the clinical setting, which is both time- and resource-intensive. Additionally, simulation sessions can be repeated as needed to mitigate skill degradation.10 Regardless of the level (low vs high fidelity), simulation is effective at strengthening multiple types of skills, including communication, teamwork, physical examination, and procedures, if evidence-based simulation practices are used and facilitators are trained. Therefore, programs with differing funding, faculty, and other resources can all implement a curriculum at their individual capacities and still achieve positive outcomes, minimizing inequity between programs.11–14 Simulation is an effective mode of education in PHM, with high learner satisfaction and demonstrated improvements in procedural proficiency and resuscitation skills.15–17 Utilizing simulation is a practical means of limiting intra- and interprogram heterogeneity in the demonstration of procedure competency.Although simulation procedure training in PHM has been described anecdotally, PHM fellowship graduates lack perceived skills and confidence in procedures.7 We recommend 3 changes for improving procedure competency in PHM fellowships: Adopt a universal shared curriculum.Optimize curricular evaluations so that they provide meaningful, actionable feedback.Integrate patient simulation scenarios into procedure workshops.We found no published examples of procedure curricula for PHM fellowships. It is at the discretion of each fellowship program as to how the ACGME program requirements for procedural competency are achieved. Therefore, despite the rigors of fellowship training, a new hospitalist’s skill at a given procedure remains variable.6 Although more descriptive requirements from the ACGME might be helpful, the most direct method for addressing this inconsistency would be the implementation of a standardized curriculum. We suggest using a sample curriculum (Figure 1) based on the combined experience of 2 PHM fellowship programs at freestanding academic children’s hospitals. Each fellowship program independently created a curriculum including practice with task trainers, patient simulation scenarios, and debriefing to review successes and learning points from the case.18 Although deprioritized from this group’s curriculum in favor of maximizing time for hands-on procedure experience, individual sites may elect to expand their curricula to include the informed consent process using standardized patient parents. The courses were refined over the span of 3 years based on the evaluations from a total of 16 fellows and later combined to form one comprehensive curriculum.Conducting medical education research at the individual PHM fellowship level is difficult given the small sizes of programs.19 Research and data sharing across programs will improve the rigor and validation of curricula by increasing sample size and showing feasibility across diverse contexts. In addition, designing effective evaluations is essential to analyze and refine any educational innovation. In our experience, we have learned that using a bipolar Likert scale to evaluate certain aspects of our curricula did not yield actionable results, because most participants simply agreed that our courses were implemented effectively. We generated more helpful feedback from free text responses (Figure 2). Therefore, we suggest blended evaluations that equally prioritize quantitative and qualitative data.Nevertheless, it is important to note that self-report may not reflect actual, observed competency. Previously, we have used Observed Structured Clinical Examinations (OSCEs) to determine when fellows had achieved competency for each procedure, although the OSCE evaluation tools were collected from several different sources and originally created for other disciplines or levels of training (eg, nurses, residents). Future versions of procedure curricula should include the opportunity to directly observe, both during and following the course, each participant’s performance level with specialty-specific evaluation tools. These tools could be part of the appendix of the curriculum and would contain checklists containing each key step of the procedures.Finally, it is unknown whether procedure workshops could improve patient outcomes within PHM. Multiple factors, such as skill decay, parental presence, uncooperative patients, time constraints, and clinical implications of a failed procedure, influence whether a procedure is successful in other specialty contexts.20,21 To truly measure the impact of such a curriculum, educators should evaluate whether simulation performance translates into practice-level changes. Practice-level impact can be evaluated within the scope of individual clinicians or entire divisions. Changes at the clinician level could be recorded via in-person or video observer. Collecting data on procedure length or success rates would be helpful for ascertaining the impact of a new curriculum on an entire division.Consistent with the fourth and final step of Kolb’s experiential learning cycle, we theorize that prompting learners to utilize the procedures in the context of a patient simulation or “resuscitation” scenario would help better reinforce participant skills and confidence.22 We identified only a few articles in which this strategy was used in pediatrics. These were in the context of residency or critical care fellowship—none in PHM.23–25 Therefore, we propose the creation of a hands-on curriculum for PHM fellows featuring procedure practice and patient simulation scenarios that would incorporate the relevant procedures. This curriculum would hold promise for PHM fellows, residents on PHM or procedure electives, and practicing hospitalists alike.26 As previously discussed, the discordance between requirements for procedure competence and real-world practice has not decreased hospitalists’ responsibility for skills in this domain, particularly as educators. Division leaders and educators should consider setting aside reserved time for such a curriculum to practice procedures and collaborating with an institutional simulation center in order to maintain procedure competency.5 Indeed, this opportunity could be considered for when hospitalists apply (or reapply) for privileges, converting what is often a routine formality into a verifiable reportable activity. Financial support via institutional collaboration is also a must to ensure programs of all sizes and resources can participate.Procedures remain incredibly important to our field as pediatric residencies deprioritize procedure training and other pediatric subspecialties like critical care prioritize the creation of procedure boot camps and workshops.19 Although the reality is that many hospitalists may not attempt the majority of the recommended procedures in their practice, as long as procedure expectations outlined by professional organizations exist, PHM fellowships and divisions should be expected to ensure procedural competency. Adopting a universal curriculum including integration of patient scenarios, with shared and optimized evaluations, would assist PHM fellows and practicing hospitalists in achieving and maintaining procedural competency.We wish to acknowledge the Las Madrinas Simulation Center at Children’s Hospital Los Angeles and the Healthcare Professionals Center for Simulation and Research at Cincinnati Children’s Hospital Medical Center.