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[page 22] [Healthcare in Low-resource Settings 2014; 2:1831]

Residents need focused teach-
ing during pediatric emergency
medicine rotation to optimize
their educational objectives
Mohammed Alomar,1 Narges Daliri,1
Awatif Alamer,1 Abdolmoneim Eldali2
1Emergency Department, King Faisal
Specialist Hospital and Research Centre,
Riyadh; 2Biostatistics Department, King
Faisal Specialist Hospital and Research
Centre, Riyadh, Saudi Arabia

Abstract

Pediatric Emergency Medicine (PEM) rota-
tion provides a unique training environment
for rotating residents. We aim to assess the
impact of PEM rotation on the scientific knowl-
edge of residents from different specialties
and training centers by comparing the pre- and
post-rotation knowledge. PEM Departments of
three major tertiary care training centers were
selected. Rotating pediatric and emergency
medicine residents were given pre-test with
twenty multiple-choice type questions related
to the scientific knowledge of PEM and then
re-tested with the same questions towards the
end of their rotation. The t-test was used to
compare mean scores. Further comparison
based on specialty and training center was also
done. Seventy-three residents were
approached and enrolled, 48 from Pediatrics
and 25 from Emergency Medicine. The mean
pre- and post-scores for all residents were
15.9/20 and 15.5/20, respectively. All residents’
score was less on the post-rotation compared
to the pre-rotation in all centers. Pediatric res-
idents at one center scored higher, but they
were not statistically significant. There were
no statistically significant differences in resi-
dent specialty. We found a statistical difference
between the residents of two centers compared
to the third with P=0.04 and 0.02 respectively.
After one month of rotation in PEM, we
observed a decrease in the post-rotation test
scores as compared to the pre-rotation scores.
Since the reasons for the lower scores could
not be identified by this study, educational
deficiencies should be identified and perhaps
a focused teaching and allotted study time to
optimize the residents educational objective
could be advised.

Introduction

The Pediatric Emergency Medicine (PEM)
rotation provides a unique training to a signif-

icant number of rotating residents by offering
them access to patients with undifferentiated
medical issues. They are afforded continuous
supervision by attending physicians.1-4 Over
the past two decades, the knowledge about
PEM subspecialty has grown through fellow-
ship programs, formation of PEM sections in
professional organizations and research.5-10

Pediatric and Emergency Medicine residents
rotating in PEM are exposed to specific cur-
riculum which has been developed by the
Residency Training Committees.11-14

Saudi Commission for Health Specialties
(SCFHS) in Saudi Arabia oversees all the
training programs including Pediatrics,
Emergency Medicine (EM) and has recognized
and endorsed PEM subspecialty fellowship
training program since January, 2005.15

Currently as per SCFHS Guidelines, Pediatric
residents spend five months [2 months in first
post-graduate year (PGY), 1 month on third
and 2 months on the fourth PGY] in PEM;
while EM residents have to spend 4 months (2
months on the second and 2 months on the
fourth PGY).16 All residents are expected to
participate and attend the didactic and practi-
cal training sessions and do at least eighteen
clinical shifts per month during their rotation
in PEM. We aim to assess the impact of PEM
rotation on the scientific knowledge basis of
residents from different specialties and cen-
ters by comparing their pre- and post-rotation
knowledge. 

Materials and Methods 

A prospective, observational, and education-
al study of the impact of one month training in
PEM at three different major tertiary care hos-
pitals in Riyadh, Saudi Arabia on the residents’
scientific knowledge was assessed by their
performance on pre- and post-rotation written
examinations. 

Study setting and population
The study was conducted in the PEM

Departments of three major tertiary care cen-
ters: King Faisal Specialist Hospital and
Research Center (Hospital A), King Abdulaziz
Medical City (Hospital B), and King Fahad
Medical City (Hospital C). These hospitals
were chosen due to their reputable established
pediatric residency and PEM fellowship train-
ing programs and the presence of a relatively
high number of trainees. Program directors
were notified by the authors. Residents at PGY
1 to 4 in the training programs for Pediatric
and Emergency Medicine that rotated in PEM
as an elective or part of their integral program
were selected.

Inclusion and exclusion criteria
All rotating residents from Pediatric and

Emergency Medicine training programs were
included during the study period. There were
no exclusions. We developed twenty multiple-
choice type questions based on clinical case
scenarios that cover resuscitation, emergent
airway management, trauma care, toxicologi-
cal and environmental emergencies with sin-
gle best answer (Table 1). The questions were
initially formulated by the principal investiga-
tor and subsequently approved by profession-
als in our institution interested in the field and
the subject. The co-investigators and a few
other PEM physicians were consulted to
review, test the questions and suggest any
modifications prior to final approval. The ques-
tions were distributed to all rotating residents
in the three major hospitals at the commence-
ment of their first shift and collected at the end
of the same shift by the principal or co-investi-
gators. All participants received the same 20-
written questions in a paper format. After com-
pletion of the rotation participants again com-
pleted the same written examination. The res-
idents were refrained from discussing the
questions and urged to complete the test dur-
ing the same shift. The participants were not
given the correct answers or critical elements
to the written test before, during, or after the
rotation. 

Measurement and timetable
The scores were given based on the correct

responses out of 20. The study was conducted

Healthcare in Low-resource Settings 2014; volume 2:1831

Correspondence: Mohammed Alomar, Emergency
Department, King Faisal Specialist Hospital and
Research Centre, P.O. Box 3354 MBC 84,
Takhassusi Street, 11211 Riyadh, Saudi Arabia.
Tel. +966.1.4424425 - Fax: +966.1.4423429. 
E-mail: momar@kfshrc.edu.sa

Key words: residents, education, pediatric, emer-
gency.

Conflict of interests: the authors declare no
potential conflict of interests.

Contributions: MA and ND, proposal writing; AA,
data collections; AE, data analysis; MA and ND,
manuscript writing.

Received for publication: 17 July 2013.
Revision received: 11 September 2013.
Accepted for publication: 25 September 2013.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright M. Alomar et al., 2014
Licensee PAGEPress, Italy
Healthcare in Low-resource Settings 2014; 2:1831
doi:10.4081/hls.2014.1831

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[Healthcare in Low-resource Settings 2014; 2:1831] [page 23]

over ten months from November 2011-July
2012.

Hypothesis and outcomes
The hypothesis is that residents shall show

improvement in their score by the end of their
rotation. Primary outcome is: change in the
scientific knowledge of the residents by the
end of their rotation. Secondary outcome is:
any difference from one center or specialty
compare to the other.

Sample size and statistical analysis
To our knowledge, based on literature

search this is the first pilot study done in Saudi
Arabia with participation of residents of differ-
ent training programs rotating in PEM. We
estimated that a meaningful difference in test
performance would be at least 10% improve-
ment in the score delta (post-test minus pre-
test). For detection of statistical significance,
with two-tailed mean comparison test with
90% power and alpha of 0.05, a sample size of
at least 22 persons in each group was needed.
This assumed a standard deviation (SD) of
mean score delta to be 10%. The student’s t-
test was used to compare mean test scores.
Completed answers were entered in an Excel
spreadsheet and SPSS version 10 statistical
packages were used. Descriptive data used in
form of frequency tables, which were generat-
ed for each resident in the test. Further com-
parison based on specialty and the training
center was also done. A P<0.05 was considered
statistically significant. 

Ethics
A verbal consent was taken from all partici-

pants and they were assured that the results of
the tests would be kept confidential and have
no bearing on their official evaluation or
future performance in PEM. Office of Research
Affairs’ approval of Hospital A (base hospital of
the investigators) approved the study before
enrollment of subjects.

Results

All approached seventy-three residents from
three centers were enrolled, 48 PEM and 25
EM. The exact number of residents enrolled
from each center is indicated (Table 2). All res-
idents completed the study during the enroll-
ment period. The mean pre and post score for
all residents were (15.9/20 and 15.5/20)
respectively. None of the residents achieved
full mark (20) in the pre- or post-rotation
score. All residents scored less on post-rotation
test compared to the pre-rotation except pedi-
atric residents at Hospital B which was statis-
tically not significant. There were no statistical
differences in the means by residents’ level
within the centers. There were no statistically
significant differences in resident specialty
between the groups (P>0.05) (Table 3). As for
the centers, there were a statistical difference
among all residents at both Hospital C and
Hospital A compared to Hospital B with a P
value of 0.04 and 0.02 respectively (Table 4).

Discussion

Riyadh tertiary care hospitals are often
thought to be ideal sites for PEM rotations
because of high acuity and a diverse spectrum
of patients. The clinical experience is some-

Article

Table 1. Contents and distribution of the
test questions.

Contents Number 
of questions

Dehydration 2
Metabolic disorders 2
Upper airway emergencies 2
Acute neurologic emergencies 2
Simple laceration 1
Management of mammalian 
bite wound 1
Orthopedic emergencies 1
Injury prevention advice 1
Lower respiratory tract infection 1
Immunocompromised with fever 1
Management of soft tissue infection 1
Sickle cell disease 1
Acid-base imbalance 1
Common congenital heart diseases 1
Differential diagnosis of common 1
pediatric rashes
Management of common 1
toxic ingestion

Table 2. Exact number of residents enrolled from each center with their pre- and post-rotation scores.

Hospital Specialty PGY level Score Number Mean score/20 SD Min. Max. P

1 2 3 4

A EM 2 - - - Pre-rotation 2 16.5 0.7 16 17 0.20
Post-rotation 2 15 1.4 14 16

Pediatrics 3 5 - - Pre-rotation 8 16.8 1.5 14 19 0.08
Post-rotation 8 15.9 1.4 14 18

B EM 4 3 11 2 Pre-rotation 20 16.3 1.4 14 18 0.15
Post-rotation 20 15.6 2 12 19

Pediatrics 8 14 6 3 Pre-rotation 31 15.4 2.4 10 19 0.72
Post-rotation 31 15.6 2.1 10 19

C EM 1 - 2 - Pre-rotation 3 17.7 1.2 17 19 0.18
Post-rotation 3 16.3 102 15 17

Pediatrics 4 4 1 - Pre-rotation 9 15.2 2.2 10 18 0.18
Post-rotation 9 14.3 2.2 11 17

PGY, post-graduate year; SD, standard deviation; EM, emergency medicine.

Table 3. Residents’ pre- and post-rotation scores according to the specialty.

Specialty Score Number Mean/20 SD Min. Max. P

EM Pre-rotation 25 16.5 1.4 14 19 0.03
Post-rotation 25 15.6 1.8 12 19

Pediatrics Pre-rotation 48 15.6 2.2 10 19 0.51
Post-rotation 48 15.4 2 10 19

SD, standard deviation; EM, emergency medicine.

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[page 24] [Healthcare in Low-resource Settings 2014; 2:1831]

what similar in all three hospitals. A tertiary
hospital is a center which caters to patients
with complex disorders such as hematology,
oncology, metabolic, immunodeficiency syn-
drome, neurologic disorders, congenital heart
diseases, trauma and many general pediatric
diseases. Even though our study may suggest
residents’ scientific knowledge did not
improve after one month of rotation in PEM
and attendance at four didactic academic ses-
sions, we certainly cannot ignore the need for
further evaluation of our training programs.
Training requirements have to be periodically
revised as educational weaknesses are identi-
fied, mainly by cross-sectional surveys of pro-
gram directors. These surveys may be limited
by recall bias and do not focus on measures of
quality, such as quantifying clinical and proce-
dural skills.17-19 Quantitative information such
as number of patients seen, resuscitations and
procedures performed enables program direc-
tors to identify training/trainee deficits, pro-
vide real-time feedback to the residents, and
make real time changes. If important skills and
knowledge cannot be attained during the rota-
tion, then simulated resuscitations and stan-
dardized patient encounters may be used to
supplement this experience. Monitoring the
types of resident clinical encounters allows the
program director to further tailor the didactic
and interactive components of the curriculum
to fill in the gaps. For example, simulation is
useful for teaching high-acuity, low-frequency
situations such as pediatric resuscitation.
While many centers may already be using sim-
ulation to teach resuscitation and other high-
acuity events, this study suggests an important
need for interactive educational experiences
to teach additional skills or concepts that have
low or no frequency during training.20-22

The efficacy of an online didactic curricu-
lum in improving knowledge acquisition
among non EM, EM rotating residents and
medical students during their EM rotations
was established. After exposure to an online
didactic curriculum, rotating residents demon-
strated a significant increase in EM knowledge
and reported a high level of satisfaction with
the didactic program.23,24 A recent survey data
show that 58% of rotating residents in academ-
ic EDs currently attend EM resident confer-

ences,25 and only 7% would prefer attending
the standard EM residency core conferences.26

It is difficult to predict didactic topics desired
by rotating residents based solely on their
respective medical specialties.27 A learner cen-
tered approach,28 allowing the resident to pick
from a selection of didactic subjects, may be an
appropriate solution. The community hospital
provides the residents with exposure to the
private practice environment, and its large
children’s Emergency Department (ED) pro-
vides pediatric EM experience. For those pro-
grams that use multiple training hospitals,
identifying the types of patient encounters in
each hospital may also help direct the residen-
cy curriculum.
According to international data, 30-40% of

ED patients present with semi urgent or non-
urgent conditions,29 the care of less acute com-
plaints is a cornerstone of PEM practice.30

Assuming that our training model is similar to
others, an alarm should be raised because the
care of lower-acuity conditions may be a train-
ing deficit. As the use of urgent care centers
and triage physicians in EDs increases; resi-
dent exposure to lower-acuity patients likely
will decreases. Residents must also be afford-
ed the opportunity to supervise and collaborate
with midlevel providers.31-33 Ensuring adequate
exposure to low-acuity conditions should be a
priority for Program Directors and should
affect the staffing plans for EDs with PEM res-
idency programs. There is a strong need for
continued research in the educational needs of
residents and evaluation of educational expe-
riences in PEM training programs. Further
studies, possibly incorporating simulation or
actual patient encounters, should be per-
formed to determine whether this improved
knowledge results in better patient care out-
comes.

Limitations
We aimed to evaluate the improvement in

knowledge acquisition as measured by scores
on a multiple-choice test. We acknowledge that
the goal of any curriculum is to achieve true
competency among learners, only a facet of
which is test-taking ability and medical knowl-
edge. Furthermore, our results might differ if
residents had been assessed by other means
like objectively structured clinical examina-

tion. Finally, these results represent the expe-
rience of only these institutions. The conclu-
sions may not be generalizable to other cen-
ters. The pretest was performed at the start
and the same questions repeated at the end of
the rotation. Some residents could have stud-
ied these questions checking for the correct
answer, though none of them score the full
marks on the post test. Thus, the majority of
interactions between the educational supervi-
sors in the ED and the study participants like-
ly occurred without confounding knowledge
transmission. While there was no way to stan-
dardize clinical teaching, shift schedules for all
participants were made based on routine
scheduling requirements by a consultant who
was not involved in the study. Shift schedules
for PEM faculty were made by a faculty mem-
ber who had no knowledge of the study or study
participant shift schedule. Therefore, there is
no reason to suspect that residents had any
significant differences in clinical teaching or
patient care experiences. We therefore feel
that the educational experience of residents
was an accurate representation of learning by
clinical practice and teaching alone. Future
studies should include a larger sample size and
multiple institutions.

Conclusions

After one month of rotation in PEM, we
observed a decrease in the post-rotation test
scores as compared to the pre-rotation scores.
Since the reasons for the lower scores could
not be identified by this study, educational
deficiencies should be identified and perhaps
a focused teaching and allotted study time to
optimize the residents educational objective
could be advised.

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Table 4. Residents pre- and post-rotation scores according to centers.

Hospital Annual PEM visits (n) PEM consultants (n) Score Number Mean/20 SD Min. Max. P

A 15,000 12 Pre-rotation 10 16.7 1.3 14 19 0.02
Post-rotation 10 15.7 1.3 14 18

B 100,000 20 Pre-rotation 51 15.8 2.1 10 19 0.59
Post-rotation 51 15.6 2 10 19

C 65,000 8 Pre-rotation 12 15.8 2.2 10 19 0.04
Post-rotation 12 14.8 2.2 11 17

PEM, pediatric emergency medicine; SD, standard deviation.

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