Author	Affiliation
Maya S. Iyer, MD	Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Department of Pediatrics, Division of Emergency Medicine, Pittsburgh, Pennsylvania

DOI: 10.5811/westjem.2014.9.23863

In Reply:

The authors are appreciative of the interest in our study provided by the author(s) of this letter. We found the Deliberate Apprenticeship (DA) model to be useful for third year medical students rotating through our Pediatric Emergency Department in regards to performing more physical exams and also having greater comfort in obtaining histories and creating differential diagnoses. Moreover, we found that this was a feasible and acceptable technique that could potentially be implemented at other institutions.
In response to the first critique of “put simply the multiple quantitative comparisons made may have yielded false positive results,” we did explore this in the limitations and agreed that multiple comparisons could have led to a Type 1 error. In fact, we took this a step further and by using Bonferroni Correction discovered that only the comfort in creating differential diagnoses remained statistically significant between the DA and control groups. This was also explicitly stated in the paper.

We also agree that the constant comparison method is a sound tool for analyzing qualitative data and was useful and enlightening in the results of this study. The students comments provide a rich description of their experience from their vantage point. We respectfully disagree that the comments provided by the medical students are concerning in their content itself. The nature of emergency medicine is to manage an ever-changing work load. As stated by Ledrick et al (2009), “part of the skill set needed for [emergency medicine] is being able to treat a large number of patients simultaneously, under pressure, and in a short period of time.”¹ We believe that the opportunity for reflection that our study provided created a safe space for students to consider and to articulate their perceptions about the learning environment and their roles as students and physicians-in-training. Therefore, the comment from one learner about being “able to jump from patient to patient” is a quality we would hope students are able to acknowledge, consider, and incorporate into their emergency medicine practice. Furthermore, going from “patient to patient” allows for increased exposure and assists with student learning in an acute care environment. Finally, the comment that this leaner appreciated the autonomy provided by “ordering tests, discharging patients” is not beyond his or her “competence” when the ultimate premise of this study was that these learners were under close supervision of a senior medical resident or faculty member.

It is an interesting idea to create an online repository to allow access to the raw qualitative data in studies. This would be particularly valuable for more extended direct observations over time, yet the implications for institutional review board protection of learners as human subjects would also warrant consideration. Furthermore, we also caution that while such a repository might facilitate further examination of thematic concepts and permit readers to have insight into the spectrum of ideas provided by our learners, providing external access to data opens the door for readers unfamiliar with the study setting to make interpretations not based on deep understanding of the training and practice site.

Footnotes

Address for Correspondence: Maya Subbarao Iyer, MD. Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Department of Pediatrics, Division of Emergency Medicine, 4401 Penn Avenue, AOB 2nd floor, Suite 2400, Pittsburgh, PA 15224. Email: maya.iyer@chp.edu.

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

REFERENCES

1. Ledrick D, Fisher S., Thompson J, et al. An assessment of emergency medicine residents’ ability to perform in a multitasking environment. Acad Med. 2009;84(9):1289-1294. [PubMed]