1. Daniel J. Schumacher, MD, MEd Mary Pat Frintner, MSPH Presented at: Association of Pediatric Program Directors Spring Meeting April 1, 2016 New Orleans, LA Graduating Pediatric Resident Training and Comfort with ACGME Required Procedures

2. Disclosure We have documented that we have no financial relationships to disclose or Conflicts of Interest (COIs) to resolve. Daniel J. Schumacher, MD, MEd Mary Pat Frintner, MSPH

3. Background The ACGME expects graduating residents to be able to perform certain procedures without supervision ACGME Program Requirements for Graduate Medical Education in Pediatrics; Revised Common Program Requirements, Effective July 1, 2015 The scope of these program requirements has narrowed with recent changes to better reflect what a general pediatrician must perform to care for his/her patients

4. Research Aim Assess whether graduating pediatric residents in the U.S.: – Receive training in 15 ACGME-required procedures Complete these procedures at least once – Desire more training on these procedures – Feel comfortable performing these procedures unsupervised Assess variation across career goals in: – Comfort with performing the 15 procedures unsupervised – Desire for more training on the procedures

5. Methods 2015 AAP Annual Survey of Graduating Residents Cross sectional survey Random sample of 1,000 graduating pediatric residents Mailed and emailed survey, up to 8 contacts, May to August 2015 Response rate: 55%

6. Methods Survey questions focused on training and self- perceived competency for 15 ACGME-required procedures Chi-square tests examined for differences in career goals (subspecialty, primary, or hospital care) for: ▪ Comfort with performing procedure unsupervised ▪ Desire for more training for the procedure

7. p<0.05 p<0.001 p=0.56 p<0.01 p<0.05 Neonatal resuscitation, 100%Venipuncture, 76% Bag-mask ventilation, 99%Simple removal of foreign body, 70% Neonatal endotracheal intubation, 99% Peripheral intravenous catheter placement, 70% Lumbar puncture, 98%Temporary splinting of fracture, 70% Simulated placement of intraosseous line, 97% Giving immunizations, 66% Umbilical catheter placement, 94%Bladder catheterization, 60% Simple laceration repair, 92%Reduction of simple dislocation, 56% Incision and drainage of abscess, 79% % of residents receiving formal training (n=542) Results Majority of residents reported formal training in the 15 procedures

8. p<0.05 p<0.001 p=0.56 p<0.01 p<0.05 Lumbar puncture, 100%Venipuncture, 84% Neonatal resuscitation, 99%Giving immunizations, 84% Bag-mask ventilation, 99%Peripheral intravenous catheter placement, 77% Simple laceration repair, 99%Bladder catheterization, 77% Incision and drainage of abscess, 92%Simulated placement of intraosseous line, 75% Umbilical catheter placement, 91%Temporary splinting of fracture, 75% Neonatal endotracheal intubation, 86% Reduction of simple dislocation, 60% Simple removal of foreign body, 86% % of residents successfully completing procedure at least once (n=542) Results Majority of residents successfully completed the procedures at least once

9. Results Over half of residents desired more training in the following procedures: Simple dislocation reduction Temporary splinting of a fracture Peripheral venous catheter placement Neonatal endotracheal intubation

10. p<0.05 p<0.001 p=0.56 p<0.01 p<0.05 Reduction of simple dislocation, 67%Simple removal of foreign body, 36% Temporary splinting of fracture, 62%Neonatal resuscitation, 36% Peripheral intravenous catheter placement, 59% Incision and drainage of abscess, 34% Neonatal endotracheal intubation, 54% Giving immunizations, 30% Simulated placement of intraosseous line, 45% Simple laceration repair, 30% Umbilical catheter placement, 42%Bag-mask ventilation, 22% Venipuncture, 42%Lumbar puncture, 20% Bladder catheterization, 41% % of residents wanting more training (n=538) Results

11. Less than half of residents felt comfortable performing the following procedures without supervision: Temporary splinting of fractures (48%) Performing reduction of simple dislocations (38%) 91% did not feel comfortable performing at least 1 procedure unsupervised 18% were not comfortable performing the majority of the procedures (8 or more) unsupervised

12. p<0.05 p<0.001 p=0.56 p<0.01 p<0.05 Bag-mask ventilation, 97%Bladder catheterization, 67% Lumbar puncture, 96%Simulated placement of intraosseous line, 56% Simple laceration repair, 88%Neonatal endotracheal intubation, 53% Simple removal of foreign body, 81%Umbilical catheter placement, 52% Incision and drainage of abscess, 80%Peripheral intravenous catheter placement, 53% Giving immunizations, 79%Temporary splinting of fracture, 48% Neonatal resuscitation, 72%Reduction of simple dislocation, 38% Venipuncture, 72% % of residents comfortable performing procedure unsupervised (n=543) Results

14. Residents with subspecialty goals were more comfortable (compared to primary care and hospitalist) doing the following without supervision: Placing umbilical catheters (58%, 46%, and 48%, p<.05) Resuscitating neonates (79%, 65%, and 69%, p<.01) Residents with primary care goals were more likely (compared to subspecialty and hospitalist) to want more training in: Incision and drainage of abscess (40%, 31%, and 20%, p<.05) Temporary splinting of fracture (70%, 56%, and 56%, p<.01).

15. Limitations Cross-sectional survey data Data based on graduating pediatric resident self-report No independent measures of procedure training or performance

16. Summary Formal training and successful completion at least once is favorable across procedures Almost 1 in 5 residents was not comfortable performing the majority of the procedures without supervision Residents with subspecialty career goals seem more comfortable performing more technical procedures without supervision Residents with primary care career goals want more training in some common procedures that they will encounter often Neonatal intubation is perhaps a procedure that receives strong focus but also one that is more technically complex, requiring additional focus to achieve comfort with unsupervised practice

17. Practical Bottom Line More training across a number of ACGME required procedures is likely needed to prepare residents for unsupervised practice

18. Acknowledgements This study was funded by the American Academy of Pediatrics Thank you to all of the 2015 graduating residents who completed this survey!

19. Additional Material

20. Program Size

21. Residents from smaller programs were more comfortable than residents from medium and large programs doing 8 of the 13 procedures without supervision: Placing bladder catheters (91%, 73%, and 58%, p<.001) Giving immunizations (91%, 83%, and 72%, p<.001) Intubating neonates (65%, 59%, and 45%, p<.01 Placing peripheral intravenous catheters (68%, 58%, and 47%, p<.01 Reducing simple dislocations (53%, 41%, and 33%, p<.01) Removing foreign bodies (97%, 80%, and 78%, p<.01 Placing umbilical catheters (68%, 58%, and 45%, p<.001) Conducting venipuncture (83%, 74%, and 66%, p<.05)

22. Program Size 24% of residents from larger programs (>20 residents per class), 14% of residents from medium programs (10-19 residents), and 5% of residents from small programs (<10 residents) were not comfortable performing the majority of the procedures (8 or more) unsupervised, p<.001

23. Program Size Residents in larger programs were more likely (compared to residents in medium and small programs) to want more training in: Placing bladder catheters (47%, 36%, and 29%, p<.01) Conducting venipuncture (47%, 41%, and 29%, p<.05) Placing intravenous catheters (65%, 57%, and 45%, p<.05) Residents in smaller programs were more likely (compared to residents in large programs) to want more training in: Resuscitating neonates (43%, 44%, and 28%, p<.001)