The structured curriculum implemented during the 4-week pediatric rheumatology rotation significantly impacted pediatric residents’ competency. The context of the pediatric residency training program provides predominantly both outpatient and inpatient clinical exposure, which also applies to context of the pediatric rheumatology clinical rotation. The curriculum led to improvements in both their knowledge of pediatric rheumatologic diseases and their MSK examination skills. Additionally, the rotation resulted in a notable increase in confidence among residents in various aspects of pediatric rheumatology clinical practice. The exit survey findings further emphasized the importance of pediatric rheumatology teaching, with a majority of residents agreeing on its essentiality. Among the requested teaching topics, management in pediatric rheumatic diseases and arthrocentesis were the two most commonly mentioned areas of interest.
Our study demonstrated that a structured curriculum incorporating a combination of teaching methods yielded positive outcomes for pediatric residents. The curriculum included interactive academic lectures, hands-on demonstrations, case-based discussions, MSK radiology conferences, topic reviews, and self-directed learning. These methods facilitated the development of cognitive and psychomotor skills, as well as the cultivation of positive attitudes toward pediatric rheumatology [5,6,7,8, 13]. Previous research has shown that case-based studies are a favored option for pediatricians [5]. This teaching method has proven beneficial during residency training [6] as the studied cases are drawn from real-life practice. Our pediatric residents were also assigned cases to review, and they discussed the tentative management plans with their supervising attending physician a day before attending the rheumatology clinic.
The 4-week pediatric rheumatology rotation had a daily schedule starting from 9 A.M. to 4 P.M. on weekdays. All activities and assessment were accommodated within these working hours. Time slots specifically for self-study were allocated. Pediatric residents may also access self-study online platforms at available time slots during the working hours or afterwards. Pediatric residents also participated in morning inpatient rounds of pediatric rheumatology patients along with the fellows on weekdays and on alternate weekends. Although this curriculum may have some similarities with other subspecialty rotations such as outpatient and inpatient consultation, attendance of outpatient clinic, topic reviews, the uniqueness of the pediatric rheumatology curriculum is its well-structured combination with various forms of teaching methods with intervention and assessment of outcomes for knowledge, skills, and confidence in clinical practice, as well as providing work-life balance for the trainees.
It is widely acknowledged that clinical exposure plays a crucial role in developing competency [15]. Workplace-based learning is fundamental in postgraduate teaching; however, the type of cases and conditions that learners encounter during their clinical practice can vary unpredictably, leading to differences in their learning experiences. To address the rarity of certain emergency conditions in rheumatology, we incorporated interactive academic lectures to cover essential conditions such as macrophage activation syndrome, catastrophic antiphospholipid syndrome, pulmonary-renal syndrome, and scleroderma renal crisis. This approach aimed to minimize variations in learning content resulting from chance clinical exposure. On the other hand, pediatric rheumatologic diseases such as juvenile idiopathic arthritis and systemic lupus erythematosus are prevalent in rheumatology clinics and inpatient consultation services [16]. In our study, we ensured consistent educational activities throughout each rotation in the academic year. Thus, the 4-week rotation provided sufficient clinical exposure to these conditions.
The pGALS screening tool, developed by Foster et al., is valuable for screening MSK abnormalities in children [11]. It has proven to be practical and applicable in various settings, including outpatient departments [12], pediatric acute care [17], and sports medicine [18]. One of the advantages of the pGALS tool is that it can be performed by individuals who are not MSK medicine or rheumatology experts [17]. The original English version of the pGALS tool has been translated into multiple languages and has gained widespread use worldwide [12, 19,20,21,22,23]. In our previous study, we linguistically validated the Thai version of the pGALS and confirmed its validity [12]. Our findings demonstrated that the Thai pGALS is not only beneficial for pediatric residents in detecting MSK abnormalities in children but also practical and well received by patients and their parents [12]. Based on these results, we incorporated formal teaching of the Thai pGALS into the curriculum development for our study. Our study also stressed the impact of formal hands-on teaching and practice of MSK examination using the pGALS tool. The results indicated that pediatric residents showed a significant improvement in MSK examination skills at the end of the rotation compared to the beginning. This finding suggests that providing formal instruction and practical training in MSK examination enhances skills more effectively than having residents rely solely on self-study with provided resources.
There has been limited research on medical education in pediatric rheumatology within the context of pediatric residency training. Gillispie et al. conducted a study that demonstrated the effectiveness of case-based discussions in improving the confidence and knowledge of pediatric residents in pediatric rheumatology [6]. Similarly, Batthish et al. found that web-based teaching modules, particularly those using case-based approaches and multimedia modalities, were valuable in teaching MSK examination methods to pediatric residents [7]. However, our study revealed a preference among pediatric residents for academic lectures rather than case-based discussions. This preference may reflect differences in individual learning styles and educational cultures between Asian and Caucasian trainees. Nevertheless, it is essential to note that according to the National Training Laboratories learning pyramid model, the student retention rate for information delivered through lectures is only 5% [24]. Furthermore, a survey study involving pediatricians demonstrated that attending academic pediatric rheumatology lectures did not significantly increase their confidence in clinical practice skills [5].
Various innovative teaching methods have become available, such as flipped classrooms, interprofessional education, team-based learning, gamification, and augmented reality [25,26,27,28]. Whether these novel approaches can be effectively applied to pediatric rheumatology remains to be seen, and further research is needed in this area. Additionally, virtual learning methods became especially beneficial during the Coronavirus disease 2019 pandemic [28]. Our program was modified in response to the pandemic so that some educational activities were delivered through the Zoom platform.
The Pediatric Rheumatology European Society has developed educational portfolios to enhance the knowledge of medical professionals in providing care for children with rheumatic diseases [8]. Additionally, the Pediatric Musculoskeletal Matters website (www.pmmonline.org) is a valuable online resource accessible worldwide to physicians and allied health professionals [8, 13]. This resource has the potential to benefit pediatricians in their practice. Therefore, we strongly encourage pediatric residents to not only utilize these valuable educational resources during their self-directed learning sessions but also to continue engaging in lifelong learning by using them.
The development of clinical competencies, as proposed by Miller in 1990 [29], follows a hierarchical pyramid model consisting of four processes. They are Level 1, “knows (knowledge)”; Level 2, “knows how (competence)”; Level 3, “shows how (performance)”; and Level 4, “does (action).” Each level can be assessed using different methods [30]. In our study, we employed multiple-choice questions to assess knowledge and the Thai pGALS tool for the performance of MSK examination through direct observation in the rheumatology clinic. Note that the posttests were conducted at the end of the rotation, reflecting short-term retention. When assessing competencies in medical education, long-term retention should also be evaluated [31]. It can be assessed through formative and summative examinations, such as multiple-choice questions, constructed response questions, and objective structured clinical examinations for the residency board examination. Additionally, workplace-based assessments using entrustable professional activities at different milestones during each academic level offer several benefits in medical education, such as feedback-seeking stimulation [32]. While our institute has implemented all of these assessment methods during training, they are beyond the scope of this study and will not be discussed in this context.
The level of confidence in pediatric rheumatology clinical practice significantly increased from the beginning to the end of the rotation. In a study conducted by Chowichien et al., pediatricians reported low confidence in MSK examination, arthrocentesis, and interpretation of rheumatology investigations [5]. Interestingly, pediatricians who had received training from pediatric rheumatology specialists during their residency showed a relatively higher confidence level in MSK examination and arthrocentesis than those who did not receive such training [5]. Previous studies have also highlighted low confidence in MSK examination among trainee pediatricians [33] and physicians from other specialties [34]. In our study, most residents initially reported a low level of confidence in the MSK examination methods at the beginning of the rotation but demonstrated a high to very high level of confidence by the end of the rotation. This marked improvement indicates that formal teaching of MSK examination and utilizing the pGALS tool are effective in improving residents’ confidence in MSK examination as well as their performance. Similarly, a study by Boulter et al. demonstrated the benefit of pGALS in enhancing confidence in MSK examination among junior doctors [35].
When assessing confidence in arthrocentesis, most residents in our study initially reported a low level of confidence at the beginning of the rotation, which improved to a moderate level by the end of the rotation. Although the statistical analysis showed a significant increase, the modest increase in confidence highlights the need to further enhance the formal teaching of arthrocentesis. Using a knee model for practicing arthrocentesis has been shown to be beneficial in improving confidence and performance among sixth-year medical students [36]. Therefore, it is recommended to introduce innovative methods such as the use of models or simulations to facilitate arthrocentesis skills during residency training.
The level of confidence in diagnosing and treating pediatric rheumatic diseases among pediatricians can vary depending on the specific diseases [5]. In our study, at the beginning of the rotation, pediatric residents reported a moderate level of confidence in diagnosing juvenile idiopathic arthritis but a low level of confidence in its treatment. This discrepancy could be attributed to their previous experiences in encountering children with joint pain, which is a common presenting symptom, and their familiarity with this condition. However, after attending the rotation, most residents reported high confidence in both the diagnosis and the treatment of juvenile idiopathic arthritis. For chronic systemic vasculitis, most residents reported an increase in confidence from low at the beginning to moderate at the end of the rotation. Limited exposure to these less common conditions during clinical training likely contributed to their initial lack of confidence. However, given the complexity of pediatric rheumatic diseases, it is recommended that early referral to specialists for further evaluation and proper management be emphasized. In real-life practice, general pediatricians are often the first to encounter these patients [2]. Therefore, during residency training, emphasis should be placed on developing competency in disease knowledge, MSK examination skills, emergency management, initial treatment, and early referral to specialists.
Several limitations in our study should be acknowledged. First, it is important to recognize the potential confounding factors that may have influenced the participants’ competency levels. Variations in clinical exposures by chance could have differed between participants, leading to potential bias. However, we attempted to mitigate this by implementing the same structured learning content and educational activities in each rotation. Additionally, the identified areas of educational needs likely reflect the residents’ clinical exposure, and thus may be different in other pediatric residency training programs with various contexts. As this is a single-center study, further studies to explore the educational needs in other pediatric residency training institution should be explored. Second, assessing competency through posttests within the 4-week rotation may only partially capture the long-term retention of knowledge and skills. While the assessment methods used to evaluate competencies and skills have been assessed as part of the pediatric residency training program, they were not explicitly evaluated within the context of this study. In this study, we did not repeat the tests and questionnaire to assess the long-term knowledge retention and confidence, nor were there formal surveys of routine pGALS examination after attending the rotation. However, these assessment methods would be of great benefit to evaluate long-term retention, and should be considered to perform at 6 or 12 months in further studies. Third, there could be possibilities to overestimate the effects of interventions and underreport of unintended consequences of the curriculum as participants who cannot complete the rotation or did not attend all activities were excluded from the analysis. To accommodate these scenarios which may occur in real life settings, we provided the opportunity for the trainees to catch up with the missed educational activities later, not limited to within the 4-week rotation, for their benefit in pediatric rheumatology education. Last, the number of participants in our study was limited even though we recruited pediatric residents over three academic years. However, it is worth noting that our center has the largest pediatric residency training program in Thailand and is the only center with year-round arrangements for residents rotating in pediatric rheumatology. Despite these limitations, the findings of our study may have potential applicability to other institutes aiming to develop a structured curriculum with educational activities within their general pediatric residency training programs.