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PEDIATRICS Vol. 109 No. 3 March 2002, pp. 404-408

Pediatric Resident Training in the Diagnosis and Treatment of Acute Otitis Media

William J. Steinbach, MD and Theodore C. Sectish, MD

Department of Pediatrics, Stanford University School of Medicine, Stanford, California

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	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objective. To investigate the presence and characteristics of formalized curricula for pediatric resident education for the diagnosis and treatment of acute otitis media.

Design. A survey was mailed to the program directors of all 224 accredited US and Canadian pediatric residency programs. Questions focused on the development, components, and teaching of any otitis media curriculum. Program directors were also questioned about their approach towards evaluating resident competency of otitis media and their future plans for otitis media-related training.

Results. A total of 144 program directors (64%) responded to the survey. Among respondents, 59% had some form of formalized education related to the diagnosis or treatment of otitis media. These curricula primarily consisted of lectures by general pediatricians <3 times per year.

Conclusions. Although otitis media is the most common disease seen by practicing general pediatricians, the Residency Review Committee in Pediatrics does not mandate formal otitis media-related training. Aside from informal case-by-case education, this survey demonstrated that only slightly more than half of all pediatric residency programs have some formalized resident education of this common pediatric problem, and most of those curricula are infrequent lectures.

Key Words: pediatric resident • otitis media • education • curriculum

Abbreviations: AOM, acute otitis media • ACGME, Accreditation Council for Graduate Medical Education

	INTRODUCTION

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Acute otitis media (AOM) is the most commonly diagnosed disease in childhood.¹ A recent study showed that in each of the first 2 years of life, children received antibiotics for an average of 45 to 50 days, and the authors attributed 90% of this antibiotic use to treatment of AOM.² Management of AOM therefore contributes substantially to the development of antibiotic resistance. It is postulated that failure to differentiate AOM from otitis media with effusion is the most common reason for misuse of antibiotics.³

Numerous studies have concluded that examination of the tympanic membrane is essential to proper management of AOM and underline the importance of teaching medical students and residents how to examine a child’s ears and accurately interpret the results.⁴ An expert panel recently reviewed the problem of misdiagnosis of AOM in infants and young children and recommended that pediatric training programs emphasize the development of otoscopic skills.⁵ They concluded that pneumatic otoscopy should be taught in medical school, and every physician who plans to care for infants and children should develop competency in the otoscopic examination as judged by experienced and validated otoscopists.⁶

Despite AOM repeatedly demonstrated as the most common pediatric problem encountered in general practice, there are no data regarding the adequacy of training within pediatric residency programs in the diagnosis and management of otitis media. Any future proposals for resident education must first detail present teaching methods. As that initial step, this survey of all accredited US and Canadian pediatric residency programs assessed the presence and characteristics of any formalized, structured resident training in the diagnosis and treatment of AOM.

	METHODS

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After institutional review board approval was obtained, surveys were sent to the program directors of all 208 general pediatric residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in the United States and the 16 in Canada accredited by the Royal College of Physicians and Surgeons of Canada. Surveys were mailed electronically to the program directors listed in the ACGME and Royal College of Physicians and Surgeons of Canada directories, whereas those directors not listing an electronic mail address received a standard postal mailing. Each mailing included a cover letter explaining the purpose of the survey. Electronic mailings included a direct Internet link to a Web-based survey; standard postal mailings included the Internet address to access the Web-based survey, as well as a hard copy of the survey and a stamped reply envelope.

The survey was designed to elicit information regarding the presence of any formalized and structured resident training in the diagnosis or treatment of otitis media, the duration of its use, specialties involved in development and teaching, the components and frequency of the curriculum, and any evaluation or feedback the residents received. "Formal curriculum" was defined as a "structured and consistent part of the residency program, not an occasional occurrence." Program directors were also queried whether they had ever evaluated any existing educational format or demonstrated enhanced competency of the residents. The 10-question survey (Fig 1) consisted of questions answered by selecting from a choice of responses and adding additional text comments in space provided. Those program directors with no response received a second mailing, either electronic or standard, and, if needed, a final third mailing.

Fig 1. Pediatric residency program directors survey.

1. Does your residency program have any formal curriculum in place for education on any of the following? (check all that apply)

   Diagnosis of acute otitis media
   

   Treatment of acute otitis media
   

   No formal curriculum in place
   

   
   
2. How long has the curriculum been in place at your residency program?

   Less than 1 year
   

   1–5 years
   

   More than 5 years
   

   
   
3. Who was involved in the development of the curriculum? (check all that apply)

   General pediatrics
   

   Infectious diseases
   

   Otolaryngology
   

   Emergency medicine
   

   Other
   

   
   
4. Who is involved in the teaching of the curriculum? (check all that apply)

   General pediatrics
   

   Infectious diseases
   

   Otolaryngology
   

   Emergency medicine
   

   Other
   

   
   
5. What are the components of the formal curriculum for otitis media and how often are they used? (check all that apply)

   (weekly, monthly, 6–11 times a year, 3–6 times a year, less than 3 times a year)
   

   (If a block rotation, then extrapolate over a year, eg, if a rotation is 5 afternoons in a single week then respond "3–6 times a year")

   1. Educational lectures by general pediatricians
      
   2. Educational lectures by otolaryngologist
      
   3. Training sessions with general pediatricians
      
   4. Training sessions with otolaryngologist
      
   5. Premyringotomy otoscopic exams with otolaryngologist
      
   6. Other
      

   
   

   
   
6. Is this curriculum mandatory for all residents?

   If no, what % residents participate in the formal curriculum each year?
   

   
   
7. Is there a competency validation/evaluation given to the residents regarding diagnostic accuracy and/or treatment decisions?
   
8. Has your program evaluated your educational curriculum and shown enhanced competency?
   
9. Are there plans to begin a curriculum for otitis media education or change any existing curriculum within the next year?
   
10. Would you be interested in helping to develop an improved educational format for otitis media resident education?
    

	RESULTS

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Of the 224 US and Canadian program directors surveyed, 144 (64%) responded, including 134 (64%) US and 10 (63%) Canadian program directors. Electronic surveys required answers to each question before allowing submission, and all written survey questions were answered. Responders were geographically diverse and represented larger university programs as well as smaller, community-based residencies. Fifty-nine percent (85/144) of responding residency programs stated they had a formal curriculum for otitis media education, with most curricula including both diagnosis and treatment (Table 1). US programs had a slightly increased frequency of formal training (59% US programs vs 55% Canadian programs).

View this table: [in this window] [in a new window]   TABLE 1. Design of Formal Otitis Media Educational Curricula

 
In general, curricula were in place for 1 to 5 years (51%) or greater than 5 years (43%). General pediatricians were the most frequently involved specialty in development (90%) as well as teaching (91%) of the curriculum. Otolaryngologists and infectious diseases specialists were involved in curriculum development and instruction in approximately 40% of responding programs, but the extent of otolaryngology participation in particular varied greatly. Some programs offered otolaryngology electives with observational clinics once a week, whereas other programs frequently used double-headed otoscopes and myringotomy for teaching. Infectious diseases specialist involvement was generally limited to lectures except 1 program whose infectious diseases division demonstrated tympanocentesis.

The majority of formal training (Table 2) included educational lectures by general pediatricians (90%). Such lectures varied in frequency, with <3 times per year (56%) the most common, followed by 3 to 6 times per year (38%). Lectures by otolaryngologists were also common (56%) and generally <3 per year (96%). Training sessions, defined as an active participation workshop to teach skills, were taught by general pediatricians in 41% of programs and by otolaryngologists in 26%. Only 15% of programs included a premyringotomy operating room otoscopic examination in their curriculum, primarily <3 times per year.

View this table: [in this window] [in a new window]   TABLE 2. Components of Formal Otitis Media Educational Curricula and Frequency (Responders Checked All That Applied)*

 
Participation in otitis media training was mandatory at 73% of those programs with an established curriculum, and participation varied by resident training level in those programs with elective rotations. Voluntary participation was estimated to be 50% to 75% of each residency training year, with higher participation in the postgraduate year-1 classes. Fourteen (16%) of 85 responding programs also evaluated resident competency in otoscopic examination, but only 2 programs (2%) had evaluated their otitis media training program itself to show enhanced competency. Only 19% of programs without curricula have plans to either begin formal otitis media education or change an existing format, but the majority of responding program directors (89%) were interested in developing an improved method of assuring resident competency in the field.

Seventeen percent of responders added comments in their surveys detailing their specific program format. Most programs with a formalized curriculum included otitis media education in the general pediatric outpatient or continuity clinic rotations, and many offered noon-time lectures or an otolaryngology elective. Unique education initiatives ranged from chart reviews, self-study modules, and an otolaryngology-generated written test to half-day workshops held by university faculty or a pharmaceutical company-sponsored mini-course held by a private infectious diseases group. Exceptional efforts included a pneumatic otoscopy workshop with the otolaryngology faculty once a year, tympanocentesis training in the general pediatric clinic, and a written test focusing on description and interpretation of videotaped otoscopic findings. Although not specifically inquired, 8 of the 85 programs with formal curricula reported use of commercially available videotapes, and 6 programs highlighted the use of specific instructional Web sites.

Many program directors described specific plans for the future. Most mentioned a desire to increase the number of core lectures about the topic, and several were actively pursuing methods of formalizing their present format and developing measures of competency. A few programs were planning to implement otolaryngology electives or include otolaryngology into an existing rotation, whereas others had plans to purchase double-headed otoscopes, videos, or schedule workshops. Several program directors responded that their associated medical schools offered detailed coursework for medical students regarding otitis media, but that the pediatric residency program had no such series.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
This survey of pediatric residency program directors in the United States and Canada determined the prevalence of formalized, structured curricula for resident education of the diagnosis and treatment of otitis media. Despite the repeated call for such educational programs,^5,6 only 59% of US programs and 55% of Canadian programs had any formalized training in place, with most consisting of lectures 3 or fewer times a year. To our knowledge, this survey documents for the first time a lack of formalized residency education for such a common pediatric condition and serves as the first step toward evaluating resident education and proposals for enhancement.

The Residency Review Committee for Pediatrics mandate requirements for accreditation of each pediatric residency. According to their latest 1997 guidelines, pediatric residency programs are required to teach residents "those procedural skills appropriate for a general pediatrician." The guidelines state "Each program must provide sufficient training in and monitor resident development ... in skills such as intubation, lumbar puncture, and chest tube placement."⁷ For those skills a formal system of documentation is required to demonstrate competency, and residents must receive feedback on their proficiency. Yet, despite acknowledging the need for competency in the diagnosis of meningitis, sepsis, and pneumonia, there is no reference by the Resident Review Committee about required education for AOM. The only mention of AOM competency is in the 1996 Ambulatory Pediatric Association Educational Guidelines for Residency Training in General Pediatrics, which highlights the diagnosis and treatment of otitis media as one of their suggested educational goals.⁸

In Canada, the recent Specific Standards for Accreditation for Residency Programs in Pediatrics, Educational Objectives in the Core Program of Pediatrics,⁹ lists, much like their US counterparts, items and skills in which residents should become fluent. Contrary to US guidelines, the otolaryngology skills requirement specifically outlines otitis media as a disease where clinical skills should be assessed by direct observation and residents are required to "perform curettage under direct vision of the ear."

Training on diagnostic techniques in otitis media have been incorporated into otolaryngology residency programs and past reviews have proposed incorporating a formal curriculum for pneumatic otoscopy into pediatric training.¹⁰ Wormald et al¹¹ studied 10 otolaryngology trainees shown 30 slides of otoscopic photographs of ears and demonstrated an improvement in diagnosis after training with another series of photographs and structured instruction. Silva et al¹² evaluated a 4-month clinical and didactic training program for postgraduate year-2 otolaryngology residents with standard readings on pathophysiology and diagnosis of otitis media and clinical training in a pediatric otolaryngology clinic for 8 hours a week for 4 months. Kaleida et al¹³ evaluated otolaryngology residents and pediatric otolaryngology fellows, also including private pediatricians and pediatric nurse practitioners, examining the ears of patients immediately before myringotomy and reported it took an average of 3.6 months to become a "validated otoscopist."

Although informal bedside medical education is the cornerstone of clinical instruction, standardized methods may contribute to improved competency and, thereby, impact the national climate of antibiotic resistance. The ideal format for adequate instruction is unknown but likely includes lectures coupled with an interactive approach with immediate feedback. The majority (89%) of program directors desired an improved educational format, but several conceded that although there were no identifiable formal lectures or workshops in their residency, the bedside explanations on a individual case-by-case basis are important. Although every residency program has informal teaching through an attending physician’s critical evaluation of ears examined by a resident, our goal was to identify any structured education beyond that case-by-case instruction.

This study has the limitations of any study relying on subjective assessment in the form of a survey. The findings are drawn exclusively from the experience and perspectives of pediatric residency program directors. However, because this group of physicians are frequently surveyed in efforts to gauge pediatric residency activities¹⁴ we believe their answers represent the accepted true status of their programs. Another limitation is the only 64% of program directors responding; however, this did represent a national sample both geographically and in program size and affiliation. It is unlikely, although unprovable, that the nonresponders have more detailed formal programs for education.

Residency programs in other specialties have formalized educational curriculums for common procedural skills.^15,16 We did not elicit comparative data regarding formal training in Residency Review Committee mandated technical skills, eg, lumbar puncture. Because our focus was on program-wide criteria, we also did not survey the actual bedside preceptors themselves—those physicians in the clinics with residents where the informal teaching in every program intuitively takes place.

The largest obstacle in devising a survey to accurately characterize any formal training was establishing specific definitions of exactly what a formal curriculum would entail. We endeavored to define terms in the survey to minimize variation in interpretation of survey questions. However, because each program director would likely prefer to consider their activities "formal and structured," including the ubiquitous informal teaching in every program, the 59% of residencies with "formal" curricula is likely an overestimate.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The need for structured, consistent training of clinicians in the diagnosis of otitis media is demanded by the prevalence of the disease in childhood. Otitis media is also the leading indication for outpatient antimicrobial use, and there are guidelines for judicious use of antibiotics as well as established diagnostic criteria.³ Other authors have commented that they are unaware of any training in medical school or residency that provides standardization of AOM,¹⁷ hypothesizing this may be because medical educators have assumed that the diagnosis of common outpatient conditions is learned quickly and requires no standardization. An expert panel specifically underscored the diagnostic value of pneumatic otoscopy, stating the correct use of pneumatic otoscopy will result in more accurate diagnosis of middle ear pathology and more appropriate antibiotic prescribing.⁶

The Outcomes Project of the ACGME is a long-term initiative designed to increase emphasis on educational outcomes of training and not the process of training.¹⁸ This movement toward competency-based assessment of pediatric residents will revolutionize accreditation standards and demand a new approach to measuring competency. Although pediatric residency programs have specific curricula as well as rigorous evaluation of proficiency in place to monitor procedural skills such as thoracentesis and arterial puncture,⁷ there is no requirement for formalized education of the diagnosis and treatment of acute otitis media, the most common disease seen by a practicing general pediatrician. In a previous survey, US pediatric residency program directors emphasized the need for clinical competency, especially the unique competencies of pediatricians that qualify them as providers of care to children.¹⁴

This study is the beginning of the critical evaluation of pediatric resident education of otitis media. Competency-based assessment of residents will raise the bar of the educational environment of residency training, which will translate into improved patient care. We believe that collaboration between otolaryngologists and general pediatricians will be an important element in developing new structured clinical training experiences to provide pediatric residents with otoscopic examination skills.

	ACKNOWLEDGMENTS

 
This study was supported by a Resident Research grant from the American Academy of Pediatrics to Dr Steinbach.

Special thanks to Thomas Robinson, MD, MPH, and David Bergman, MD, for help with survey design; Michelle Mayer, PhD, MPH, BSN, and Charles Prober, MD, for critical review; and Thomas Steinbach, BS, for help with the Web-based survey application.

	FOOTNOTES

 
Received for publication Aug 6, 2001; Accepted Oct 4, 2001.

Reprint requests to (W.J.S.) Box 3499, Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC 27710. E-mail: stein022{at}mc.duke.edu

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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics

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