The Pediatric Milestones are now being used to guide the ongoing evaluation of trainees in all rotations. Certainly the most important Milestones vary from rotation to rotation. In the Pediatric Emergency Department (as in many others) making sure that you develop an effective plan for diagnosis and treatment is critical.
This post is all about what we do multiple times a day: Developing a plan of care and carrying it out. Early/novice residents rely on theoretical knowledge that they gained in medical school. Having not seen the condition, especially in the context of the ED they lack the previous experience and knowledge of intermediate and advanced learners. The most inexperienced clinicians can’t sift through information to arrive at key details. Therefore clinical judgment seems arbitrary. An example is the patient with multiple medical problems presenting today with a seizure. Experience allows trainees to focus in on the key problem and not worry about other issues like a leaking gastrostomy tube that otherwise gets equal attention as the seizure in the case of the novice trainee.
It is also critical to note whether or not a resident is practicing in a manner that is primarily due to prompts and direction from supervisors, or the hospital as a whole. Novice physicians make decisions based on directives from their supervisor or what is “usually done at this institution.” Essentially they have a lack of understanding of the rationale or importance to the patient. They may know to give dexamethasone to a patient with croup but either miss that the patient actually has a foreign body, or lack understanding as to exactly why we give dexamethasone in the first place (like promising the family it will help now – as opposed to reducing the risk of a return visit to the ED).
To effectively assess this milestone as a supervisor:
- Try to provide as much autonomy in decision making as possible. This can be uncomfortable for you, so set limits that you are comfortable with. Mentors of mine would state that you can do what you want, as long as you have a good reason and can back it up. Exceptions included performing an LP or other impactful procedure, ordering a CT or calling a consultant that had not referred the patient into the ED.
- Avoid consciously “prompting” residents so that they arrive at the plan that you prefer.
- Attempt to understand why the resident has made certain decisions about patient care, and provide education when there are gaps in their knowledge. Ask them why they ordered certain diagnostic tests and treatments. This opens up great avenues for teaching.
- Accept that sometimes the resident’s plan may be different from yours. Allow variation when supported by the literature, and when it is safe to do so within the context of the individual patient’s care and the climate of the ED as a whole. Dexamethasone instead of prednisone in asthma exacerbations for instance. Reglan instead of Compazine for a migraine.
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