Teamwork on Rounds on an Inpatient Ward Team: An Ethnographic Study

The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study

BACKGROUND AND OBJECTIVES

With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams.

METHODS

In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis.

RESULTS

Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows.

CONCLUSIONS

This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

Defining Supervision Preferences and Roles Within a New Subspecialty: Pediatric Hospital Medicine

OBJECTIVE

To describe supervision preferences among pediatric hospitalists, Pediatric Hospital Medicine (PHM) fellows, and senior residents (SRs), and to better define the ideal role of a PHM fellow.

METHODS

We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys, one for each population (hospitalists, fellows, SRs). We calculated univariate descriptive and bivariate statistics for categorical variables using Chi-square tests with the Rao-Scott correction to account for clustering by institution.

RESULTS

Survey respondents included 106 of 200 hospitalists (53%), all 20 fellows (100%), and 149 of 380 SRs (39%). Most hospitalists and all fellows preferred the supervising hospitalist to have 3+ years of experience or be fellowship-trained. Nearly all fellows preferred the attending round in-person providing progressive independence; while hospitalists and SRs desired greater attending presence on rounds. Hospitalists and fellows wanted more frequent communication when the attending does not round with the team, and more hospitalists desired at least 2 points of contact regardless of attending presence on rounds. Fifty-five percent of SRs reported experiencing much less/less autonomy when on with a fellow than when supervised by a hospitalist only. Regarding the fellow's role, most participants agreed SRs should lead rounds and contact the fellow first with questions. The majority agreed teaching should be a shared responsibility but lacked consensus about how to provide feedback.

CONCLUSIONS

Study results reveal preferences about supervising fellows in this new subspecialty. Hospitalists, fellows, and SRs may have differing opinions regarding workflow, communication, and teaching, impacting team leadership and autonomy.

Pediatric Family-Centered Rounds and Humanism: A Systematic Review and Qualitative Meta-analysis

CONTEXT

Pediatric family-centered rounds (FCRs) have been shown to have benefits in staff satisfaction, teaching, and rounding efficiency, but no systematic review has been conducted to explicitly examine the humanistic impact of FCRs.

OBJECTIVE

The objective with this review is to determine if FCRs promote the core values of humanism in medicine by answering the question, "Do FCRs promote humanistic pediatric care?"

DATA SOURCES

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Dissertation Abstracts for peer-reviewed pediatric studies through January 1, 2020. We used search terms including FCRs, communication, humanism, and the specific descriptors in the Gold Foundation's definition of humanism.

STUDY SELECTION

Abstracts (n = 1003) were assessed for 5 primary outcomes: empathy, enhanced communication, partnership, respect, and satisfaction and service. We evaluated 158 full-text articles for inclusion, reconciling discrepancies through an iterative process.

DATA EXTRACTION

Data abstraction, thematic analysis, and conceptual synthesis were conducted on 29 studies.

RESULTS

Pediatric family-centered rounds (FCRs) improved humanistic outcomes within all 5 identified themes. Not all studies revealed improvement within every category. The humanistic benefits of FCRs are enhanced through interventions targeted toward provider-family barriers, such as health literacy. Patients with limited English proficiency or disabilities or who were receiving intensive care gained additional benefits.

CONCLUSIONS

Pediatric FCRs promote humanistic outcomes including increased empathy, partnership, respect, service, and communication. Limitations included difficulty in defining humanism, variable implementation, and inconsistent reporting of humanistic outcomes. Future efforts should include highlighting FCR's humanistic benefits, universal implementation, and adapting FCRs to pandemics such as coronavirus disease 2019.