Keystone: Exploring Pediatric Residents’ Experiences in a Longitudinal Integrated Block

Abstract

Problem: Residency training in many specialties has traditionally been divided into short, discrete, single-specialty rotations. Although providing the learner with in-depth exposure to a specific discipline, educators have challenged this rotational model, citing problems with patient and team continuity and maladaptive coping. Longitudinal integrated clerkships, adopted by many medical schools, offer an alternative model and have demonstrated improved outcomes for students related to patient-centeredness, advocacy, and integration with teams. Despite this, longitudinal integrated training in residency is rare. Intervention: We developed a novel 3-month longitudinal integrated block for residents, called Keystone. The block combined 3 previously discrete, shorter rotations in developmental-behavioral pediatrics, advocacy, and emergency medicine into a longer and integrated experience. Within each week, the block utilized half-day sessions in the resident’s primary care clinic, a new continuity Developmental Behavioral Pediatrics clinic where the resident worked with the same faculty preceptor and interprofessional team each week, shifts in the emergency department, and half-day sessions dedicated to clinic- and community-based advocacy activities. Context: The context was a single, large pediatric urban residency program based at 2 university-affiliated hospitals, an academic freestanding children’s hospital, and academic safety net hospital. Outcome: Using a phenomenologic framework, we conducted interviews and a focus group discussion to explore residents’ attitudes about the block; their perceptions regarding the block’s impact on relationships with preceptors, peers, or patients; and the block’s impact on learning and practice. Fourteen residents participated, 10 in interviews and 4 in the focus group discussion. Six themes emerged from thematic analysis: (a) the longitudinal nature of Keystone influenced professional relationships and as a result entrustment, (b) the longitudinal integrated design shaped engagement and learning, (c) flexibility promoted work–life balance and self-directed learning, (d) learners experienced time and space for professional identity development, (e) Keystone provided a unique opportunity to reclaim patient-centeredness, and (f) learners experienced important advantages and challenges related to the schedule. Lessons Learned: The longitudinal integrated nature of Keystone provided a novel structure for addressing important yet challenging educational goals in residency, including enhancing relationships, facilitating entrustment and engagement, encouraging patient-centeredness, and emphasizing the importance of self-directed learning.

Keywords:

• graduate medical education
• longitudinal integrated training

Acknowledgments

We acknowledge the Joel and Barbara Alpert Endowment (Boston University School of Medicine) for its support of this study. We also thank Theodore Sectish, Ronald Samuels, Kenneth Michelson, and the Keystone rotation directors for their leadership and contributions to Keystone, as well as the residents, chief residents, and program leadership of the Boston Combined Residency Program for their commitment to continuously improving the training program.

Disclosure statement

The authors report no conflict of interest to disclose.

Additional information

Funding

This work was supported by the Joel and Barbara Alpert Endowment, Boston University School of Medicine, Boston, MA.