See One, Do One, Teach One May Be Traditional, But There’s a Better Way!

Sakina Sojar,¹ Caitlin Li,² and Lauren Goverman³

1)      Pediatric Emergency Medicine Fellow, PGY4, Hasbro Children’s Hospital, Brown University

2)      Pediatric Resident, PGY3, Massachusetts General Hospital for Children

3)      Pediatric Resident, PGY2, Massachusetts General Hospital for Children 

See One, Do One, Teach One May Be Traditional, But There’s a Better Way!

Learning how to do procedures as a trainee can be exhilarating but stressful. Not only do you have to remember all the steps of the procedure, which supply closet has the extra LP needles, and what percent lidocaine your attending prefers, it’s also essential to obtain high-quality informed consent. For many skills that residents learn, there’s a standard resource they can use to make sure they’re not letting anything slip—shouldn’t they be equally supported in obtaining informed consent?

Lumbar punctures are one of the most common procedures performed by pediatricians, and we noticed that every resident has their own style for obtaining informed consent. Interns learn from their senior residents and attendings, then adapt the consent process fit their own style. After a literature review, we decided that the best strategy to address this variation in consent quality would be to create an electronic tool that could guide the process and ensure that every family had an equal opportunity to learn about the risks and benefits prior to consenting to the procedure.

As a team, we designed a prototype model that could be displayed on an iPad, then went through cycles of cognitive interviews with families who were visiting the pediatric emergency department. Each cycle, we implemented families’ suggested changes into the tool until we consistently received feedback that they liked the design and felt that it helped them adequately understand the procedure. Like any research project, we ran into delays ranging from IRB submissions to lack of space in the busy emergency department, but in the end we were pleased to have a tool that can improve the quality of care we provide to our patients. We’re looking forward to integrating it into pediatric residents’ clinical work flow!

For us, this project reinforced the importance of teamwork and collaboration. By having multiple residents working together, we were able to move forward even when some of us were on busy clinical rotations, and we were able to see the project through to the end even when our fearless leader moved to another institution to start her fellowship. We also realized what a valuable resource the GME office is, and we’re so grateful to them for supporting this project!

Making life a bit simpler – a voyage of discovery through the IRB

Yvelynne Kelly, MD

Nephrology 

PGY-9

October 10, 2018

Last Fall I was privileged to become a recipient of a prestigious Brigham and Women’s Hospital Centers of Expertise Quality and Safety Research Award for my proposed randomized controlled trial comparing tunneled dialysis catheter to non-tunneled dialysis catheter use for renal replacement therapy in the intensive care unit. I have long had a passion for critical care nephrology and had seen first hand the difficulties that can arise with temporary dialysis catheter use for emergent renal replacement therapy. My mentor, Dr. Mallika Mendu, and I decided that the time was well overdue for a high quality randomized trial to give an evidence-based answer as to whether the complication rate with randomization to non-tunneled dialysis catheter use is greater than that associated with tunneled dialysis catheter insertion.

This was my first foray into designing and initiating a randomized controlled trial. What a journey it has been…and, in a sense, we have not yet really begun. We met with interventional nephrologists and critical care nephrologists to bring about a trial design that would be feasible and sufficiently powered to answer our research question. We registered the trial with www.clinicaltrials.gov. I updated my Good Clinical Practice certification. We applied for a $100,000 grant, got amazing feedback, and then, at the last hurdle, the organization decided that they were not interested in a study that focuses on acute kidney injury, as opposed to chronic kidney disease. Still we continue to battle through the grant minefield… In a sense, however, the greatest obstacle has been getting IRB approval. This finally came through in September 2018 after six months of preparing and submitting three different iterations. Like grant writing itself, gaining ethical approval follows a learning curve of honing and refining critical thinking and writing. In the case of IRB approval, however, it serves as a timely reminder of the need to be truly patient-focused, both as clinicians and researchers. One of my stumbling blocks, in particular, was producing a patient consent form that was, in retrospect, far too detailed and medically orientated. I was more interested in telling them every single little thing that could happen, in complete detail, rather than providing a broad overview and simplifying/clarifying language in a manner that would have been beneficial to all involved.

Here’s the take-home point for now, until the trial starts in earnest and all opportunities for learning begin to multiple exponentially: we need to focus on our patients; their wants, needs, fears and frailties. That way, we can shrink the paperwork and apply ourselves more fully to the true task in hand – providing safe, efficacious and quality care for those whom we serve.