#303 - Improving resident debriefing following critical events in the NICU

Hello friends👋

In this episode, I had the pleasure of speaking with Dr Kelsey Kirkman who is now a third year Neonatology fellow at Texas Children’s Hospital. Kelsey shared with us her primary fellow project on creating a debrief tool for residents following critical events in the NICU. She describes in depth about how she came up with this idea and how she found her mentor to help support and navigate her medical education interest.  We talked about medical education theories and how to perform a thematic analysis. We talk about her challenges in implementing her project and how she tackled them. We also discussed how she took her medical education research to the next level by pursuing a Masters in Medical education through UT Houston. She shared insights on how she balanced fellowship training with her masters. Kelsey also shared her lessons learnt from her experience and provided some of the resources that helped her understand medical education better. Kelsey hopes to have a medical career in a leadership role, leading a training program, and applying her knowledge in medical education in improving neonatology subspeciality training. 

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Resources

Dr. Lara Varpio. Select paper examples: 

1. Regher G., Varpio, L. (2022). Conferencing Well. Perspectives on Medical Education. 11(2): 101-103.

2. Kiger, M., Varpio, L. (2020). Thematic Analysis of Qualitative Data: AMEE Guide No. 131. Medical Teacher. 42(8):846-854

3. Varpio, L., Young, M., Uijtdehaage, S., Paradis, E. (2020). The distinctions between theory, theoretical framework, and conceptual framework. Academic Medicine. 95(7):989-994.

Medical Education Podcasts: 

The Papers Podcast: https://paperspodcast.ki.se/ 

Key LIME Podcast: https://keylimepodcast.libsyn.com/ 

MedEd Publication Portal: 

https://www.mededportal.org/

Questions about pursuing research in medical education or a MEd, can contact me: kelseykirkman93@gmail.com 

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Short Bio: Dr. Kelsey Kirkman completed her medical school education at UT southwestern in Dallas, Texas. She then went to Baylor College of Medicine in Houston for her categorical pediatrics residency training and stayed for her neonatology fellowship. She is currently a third year neonatal fellow.  During her fellowship, she has been working on obtaining her master’s in education from the University of Houston with plans to graduate in Spring 2025. Dr. Kirkman is also a simulation instructor, resident noon conference lecturer, and helped as an instructor for the onboarding course of new neonatal advanced practice providers. She plans to continue her passion of working in medical education as she begins her neonatology faculty career at Vanderbilt University Medical Center in Nashville, Tennessee next year. 

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The transcript of today's episode can be found below 👇

Srirupa (00:01.25)

Hey everyone, welcome back to the next episode of the Fellows Corner with the Incubator podcast. I am very excited to welcome the next guest on the show, a very good friend of mine, Dr. Kelsey Kirkman from Texas Children's Hospital. Kelsey did her medical school at UT Southwestern in Dallas, has been a Texan all through, I suppose, right Kelsey?

Kelsey Kirkman (00:24.001)

Yes.

Srirupa (00:24.238)

Went on to do her Pete's residency at Texas Children's Hospital and that was followed by her fellowship that she's currently pursuing with Texas Children's Hospital as well. Kelsey has a lot of interest in medical education, is a very enthusiastic teacher, is a simulation instructor and has done so many things in her pathway to be a medical education researcher. And we're going to hear all about her interest and passions and talk a little bit about her project.

where she looked at developing a novel tool for resident educational debrief for critical events in the NICU, which I think is such an important topic. Welcome on the show, Kelsey. How are you doing today?

Kelsey Kirkman (01:07.795)

Great. Thank you so much, Rupa, for letting me be on today.

Srirupa (01:11.278)

Yes. So I'd like to first hear from you about your project. I know that when I was Kelsey's fellow, we were co-fellows, I remember that she was so interested and enthusiastic about her project. And I would love to hear how the project has progressed over your course of your fellowship. Tell us a little bit about it.

Kelsey Kirkman (01:32.119)

Sure. So I decided to focus my fellows research project on medical education. And medical education is always something that I've been very passionate about probably since undergrad and since medical school. I've always loved learning and I've loved sharing tips and making study guides to help others learn and make learning easier. And so I knew that when I needed to do a fellows project as we all do that my passion for teaching and finding innovative ways to learn would

kind of help guide me into a medical education research project. And so I reflected back on to when I was a pediatric resident and I was taking care of the sickest of the sick kids in the PICU and the ER and even in the NICU and other acute care units. And I unfortunately like many, other pediatric residents experienced and participated in several codes and resuscitation events. And as the frontline provider,

we all know that those events can be pretty traumatizing and distressing and even difficult to understand what clearly happened. And so a lot of times in my own personal experiences, these traumatic critical code events were either never debriefed or there was a debrief. I ended up leaving the debrief with more questions than answers.

and I didn't fully understand what had happened. And so that's when I had the idea of somehow standardizing how we do our debriefs and tailoring them specifically for resident education. And so now we have, through this project, created a debrief tool for resident medical education that we implement after a critical event that happens in our NICU.

And it's a way for the facilitator, whether that's a fellow or an attending that was on call during that code event, to sit down with the resident and go through the guide. It's merely just a guide. It's to help you go through the questions of emotional processing and then getting into educational and knowledge retention. What happened? What were the interventions? Why did we think this happened? What was the pathophysiology that could be going on? And how can we apply and learn from this in the future?

Kelsey Kirkman (03:43.277)

And so our goal is to, right now we're implementing the debrief in our NICU, but then our goal is to disseminate this hopefully to other units throughout the hospital so that other departments can benefit from it.

Srirupa (03:59.61)

That's amazing. And I do agree, you know, when, when we are sort of residents, unless you're actually interested in the subspecialty, for example, in the queue in this situation, you're like confused about your role. And that's, that's the honest truth of it, because you are just there where you are supposed to be there. But then at the end of it, you leave traumatized because you've either seen a bad outcome or you've seen something that's

somehow went into a good outcome, but you've not understood where and how those things happen. And as a resident, I feel like that is so important because it contributes indirectly to burnout and everything as well. Not knowing, not understanding. And so that's fantastic that your tool is so designed to help with that. Tell me a little bit about how you designed the tool. And I know that you have like a lot of interest in medical education. How did that apply to designing this tool?

Kelsey Kirkman (04:47.383)

Sure.

Kelsey Kirkman (04:53.263)

great, great question. So when we developed this tool, we first looked at the literature to see what other tools were out there and available that we could use as inspiration. And surprisingly enough, there are no debrief education tools that are used for in situ for in the clinical environment. A lot of these debrief tools that are published and available are for simulations. And this is completely different where you do have a lot more emotions and

and a lot more to discuss usually. And so we first looked at the literature and then we used some educational theories and frameworks, which I can talk about a little bit later, to help kind of guide what we wanted to be included into the tool. And then we did a resident focus group just to talk with residents about what they want in the tool and what they value in.

debrief, what kind of questions that they think are important. Taking that together, we came up with just an initial template, initial draft of what the tool would be, and then we did a Delphi consensus model, which is where you go to expert physicians, which we've had experts in the PICU, the ER, and the NICU, all attendings in those fields, to read through our tool and go through several rounds of iterations where we come up with changes and suggestions.

until we come to a general consensus on this is what we agree is what it should look like. And we made sure that it was very consistent to what the residents were telling us that they wanted in the debrief.

Srirupa (06:32.098)

Yeah, no, that's amazing. And how was this tool sort of, is it a paper tool? Is there an app? Like how was the tool typically generated?

Kelsey Kirkman (06:40.951)

Great, great question. So right now it is a laminated tool and guide that's in all the resident workrooms in our NICUs. I think that would be great to develop an app as well. I am not tech savvy, but I think you can easily try to figure that out and at least have some kind of QR code that at least they can easily access it on their phone would be great. But yeah, it's posted everywhere throughout the unit and especially in the resident workrooms.

Srirupa (07:08.046)

That's amazing. since this was quite focused on the residents, I guess my question to you was how did the residents feel about this? You you are trying this method or a debrief tool where your study population is probably the residents. So how did they feel about it? How was the general sort of reaction to that? Not just amongst the residents, but even like staff in general.

Kelsey Kirkman (07:31.125)

It was very well liked. We had a lot of overwhelming positive response from the residents and the facilitators that used the tool. We're still going through all of our analysis that we're doing for our interviews because after the residents got a chance to use the tool, did sit down with them and did a semi-structured interview with them just to learn more about their experience and be able to

understand if how the tool is working for them and is it effective. And so we're still analyzing a lot of that data right now, but overwhelmingly it's very positive. They feel like having a guided structure is great because a lot of times there's so much variability in how a debrief is done. And this is really focusing on what they want to learn and it's very much tailored for the residents and for their medical education.

Srirupa (08:28.216)

And that's amazing. And I'm pretty sure they all appreciated your advocacy for that. So that's wonderful. Tell me, you mentioned thematic analysis. And for a second, I was like, OK, what does that mean? And I'm pretty sure that's a new word for a lot of people who are not involved in medical education research, which I also sort of have heard a lot of people use a lot of educational theories. And I would love to hear.

your words what those mean to see if maybe I could apply that to my board studying so please share

Kelsey Kirkman (08:57.517)

Yeah, definitely. So medical education research, which is kind of its own qualitative research, is very unique. It's very different than what we're typically used to where we learn about the scientific method and we get all this data and we go through statistical analysis to analyze that data. Qualitative research is answering different kind of questions. It's answering questions that are like,

why questions or how questions, trying to get more understanding and perspective from your topic and from your research subjects that you're using. Versus quantitative is more, of course, like what and how much kind of questions and more looking to identify patterns and relationships. And so with medical education, qualitative research, you don't

necessarily get this data where it's chart review data or biochemical lab data. Instead, you're getting interviews or you're getting transcripts from focus group sessions. You're getting a lot more qualitative data. And so how do you sift through that to understand what is there and what can I understand and take away from that? And that's where thematic analysis comes in.

And that's essentially is where I had my semi-structured interviews. I transcribed all the interviews and I have coders. And essentially as a coder, you read through the transcript and you're looking for common themes and things that are sticking out. satisfaction with the tool, that's one code. Maybe a barrier to debriefing, okay, that's another code. And you start coding through the entire transcripts.

And then you come together all the coders and try to identify common patterns and group those together. And then once you identify those common patterns, you try to group together those into common themes. And so then you can kind of leave with your analysis saying, okay, from all these transcripts, we now understand that residents want this from a debrief and that using this tool, they felt this way. That's kind of where you can get

Kelsey Kirkman (11:16.193)

those common themes and where you can truly analyze your data in qualitative research.

Srirupa (11:22.508)

No, that's amazing. And I think that it's so, like you rightly pointed out, know, medical education research is such an important niche that, you know, you have to go in depth into like understanding these theories and kudos to you that you've done a fantastic job going in depth. and in the same context, I'd like to understand or share with us how you found your mentor and how that relationship sort of flourished during fellowship, because I'm pretty sure that for an education that is so high yield like yours.

you need someone to back that up who's probably doing great things in medical education as well.

Kelsey Kirkman (11:58.325)

Yeah, for me it was incredibly helpful that I was coming from the same program that I did my residency training. So I kind of already knew some people in our NICU division that were a little bit interested in medical education and that was our fellowship program director, Dr. Melissa Carbajal. She had not only a very strong interest in medical education, but also a background and was pretty knowledgeable on medical education research. so.

One of the big reasons of why I stayed at Baylor for fellowship was that availability for mentorship and medical education and that we did have those mentors available. And I'm very fortunate because I know there are also a lot of other strong medical education leaders, not only in our division, but also throughout the Department of Pediatrics. And so those also people helped connect me to people that would be very valuable for my scholarship oversight committee.

And I think it helps that I'm coming from a program and an institution that's very large. And so we have those resources and those people available. I know this can be challenging for other fellows that are maybe across the country that maybe don't have as many medical education research leaders. It's a pretty new field that people are doing scholarship and research in. And so especially in neonatology, as compared to probably clinical and translational.

and basic science work. So hopefully we'll start getting more people that are interested in medical education to hopefully have more mentors available for future fellows.

Srirupa (13:33.976)

Yeah. And I think that one of the biggest reasons that I was interested in creating this platform for fellows is cross-institutional mentorship. And I think that, you know, it gives an opportunity for even mentees from smaller institutions who would like to connect with these bigger institutions where there are so many people who have that background of medical education for them to sort of pursue their interest. And my hope is that this platform helps with that. so it's wonderful that you shared that with us.

Kelsey Kirkman (13:42.143)

Mm-hmm.

Srirupa (14:04.204)

I always want to understand, you know, fellowship is such a tough period. It's such a beautiful yet challenging in a lot of ways because you're growing as a person, you're growing as, as an unitologist. And what I'd like to understand from you is with this interest in medical education, how did you sort of move forward in these three years? Like how did the fellowship support in your goals of being, of taking medical education?

as part of your career pathway.

Kelsey Kirkman (14:35.331)

man, my division was incredibly fortunate and think are incredibly fundamental in allowing me to grow in my passion for medical education. They were very supportive and I think it helps that the program director is herself interested in medical education. And I would extend that to beyond our division, but to the Department of Pediatrics in general at Texas Children's. They had this wonderful

scholarship that was available for fellows that were interested in pursuing additional training and additional education. And part of my passion in medical education was to get a master's in education. And I thought not only would that help me become a better clinical educator, help me learn how to best teach the residents on rounds and give lectures that are engaging and help the residents

and fellows in my future to absorb the information from my lectures too. And so that's where I became interested in wanting to get my master's in education. And because the Department of Pediatrics had this wonderful scholarship available, it made it much more easy for me to pursue getting this master's in education through the University of Houston. It's been.

Truly a wonderful and very grateful experience that I've had. I'll be able to complete my master's in the spring of next year in 2025.

Srirupa (16:06.072)

That's been amazing. And I remember you trying to schedule yourself to make sure you're available for your classes. How is that experience like balancing doing your master's and your fellowship training together? Because I'm pretty sure a lot of the fellows would love to know how do you balance that and pursue this during fellowship.

Kelsey Kirkman (16:24.929)

Getting a master's while you're in fellowship is hard work, for sure. It's a hard time when you're a full-time fellow in balancing your service time and your call schedule, for sure. I am incredibly fortunate that the University of Houston, their master's in education for healthcare professionals, which is also wonderful. It's really geared towards healthcare professionals, is all online.

So it's all online coursework. Most of the classes, if not like, I would say 90 % of them were all asynchronous, which means that I could just log on whenever I wanted, get my work done, when on my own time, my own schedule, submit my work by the end of the week, and I would be able to stay on track with all my schoolwork. There were a couple times where there were some synchronous lectures. If I was available, I'd...

course login, but if you didn't, they would be recorded and you could watch it later and still be able to participate in some kind of discussion on their online platform as well. that was made it so much easier to be able to get it done. think if and maybe that's because of, you know, COVID times, we've now moved to more online education and more online, you know, college work. But

it definitely helped make it easier to do as a fellow.

Srirupa (17:46.488)

Yeah, no, I agree. think the flexibility of receiving education through online platforms is a game changer in so many ways that you are able to get what you need from your house. And that's wonderful. And it's as effective, if not better, because you are a little bit more flexible with your time and you actually pay attention based on your mental frame, I suppose, which is wonderful. Speaking of challenges, tell me a little bit about

your project and how, first of all, were there any major challenges? And that's a little bit of an interesting question because which project does not have challenges, right? Like I feel like every research project comes with challenges and while you implemented your project and while you sort of introduced your project into the residents or amongst the residents, what were some of the challenges that you faced and how did you tackle them? I would love to hear that from you.

Kelsey Kirkman (18:42.197)

Yeah, yes, every project has challenges. I had a couple of them. My first one that I can think of is that my debrief tool is used after a critical event that happens in the NICU and the NICU ebbs and flows with acuity. Some months with the residents, there were no critical events that needed to be debriefed that the residents participated in. Some months it was plentiful.

So I would say trying to be able to use the tool with every resident group was challenging because there were some months that the residents had actually a pretty low acuity month and there weren't any codes or any big resuscitations that warranted using this tool. And then my second one was participation in general.

That was pretty challenging for the project. I needed a lot of buy-in. I needed buy-in from the facilitators that were doing the debriefing, the fellows or the attendings that were on service or on call that night that this, you know, maybe code happened. We're a large institution. We're a large division. So I had to make sure everyone was aware of my debrief project. We have many, many, many faculty in our division. And so I had to, you know, present at multiple faculty meetings.

multiple research conferences to try to educate and encourage the use of my debrief tool. And beyond that, it was more, I had to even personally start reaching out to people after events would happen to try to make sure that we were able to use the tool. Incentivizing is what helped me tackle this challenge. Definitely in the beginning, using gift cards or things like that if you were able to use the tool.

definitely helped encourage its use. But then after facilitators and residents started seeing how useful it was and actually they could benefit from it, think it just in of itself that made it easier to encourage its use in the future.

Srirupa (20:41.516)

Yeah, no, I feel like for the most part, you, you know, getting work done from other people, getting them to use your tools is probably the biggest challenge you have, right? Because people are just in sort of this carousel of like just doing clinical business. And so it just gets to the point of like focusing on research. So I'm glad that you had some support from your facilitators, from the institution and from the department to facilitate that. That's wonderful. while we were, while you were talking about the resident, was

kind of thinking how did the nurses and the other staff kind of take this and is there every any chance in the future that you could kind of simulate this as a more standardized tool for all members of the group itself like the medical staff itself? In the same context, do you have plans to sort of disseminate this tool in other places which might have critical events like you had mentioned PICU, ED and yes, we want to focus on NICU because we're all neonatologists but

This, think, a very, it's a tool that can be applied to other aspects of medicine as well. My question in brief is, how did the other medical staff take your tool and is there a possibility of its application beyond the residency program itself?

Kelsey Kirkman (22:00.727)

Great questions, Rupa. So that brings me to highlighting one very unique thing about my debriefing tool is that it's not a hot debrief. It's not meant to be. It's not meant to be right after the event happens and you go and find this guide and you sit down and do it because we all know that there is a component of emotional distress that happens when you participate in a code like that and we all need time to process it.

So my tool is two part, it's, you know, the very first part is making sure that everyone has had the time to emotionally process the event before going into the medical education aspect of it. And so because of that, these debriefs are usually met days later. And we, you know, specifically designed it so that it would just be the resident with the facilitator because from our needs assessment and our focus groups with residents, we have learned

that residents don't feel like they can actively participate in a debrief or speak up when there's a lot of other interprofessionals that are there. And that they specifically wanted to learn something that would help make them a better clinician, that would help them with either preparing them for their future if they want to become a neonatologist, if they need to be a hospitalist and be able to take care of maybe a sick newborn.

or if they need to of course pass their boards. And so knowing how to recognize shock and how to treat that are things that residents need to learn. And so this is very much a tool geared for resident education. I have not heard of any other nurses or RTs so far wanting to kind of engage with these kind of debriefs. do offer in our units, we do hot debriefs as well as we have a different

discern tool that focuses on safety events that focus on systematic issues that of course is very much needed and that's usually always done as a hot debrief right after the event with everyone that's participating so that the nurses and RTs and everyone still can get a chance to debrief because it is still important that everyone have that opportunity to debrief. This tool just approaches it from a different perspective and from a different goal and a different aim at focusing really just on what

Kelsey Kirkman (24:21.025)

the residents need to learn and focus is just for them. there are definitely, you can definitely broaden this and change it up so that it can be more applicable in different institutions for a more wider population for sure. And I would still encourage hot debriefs and things to occur right after the event with everyone and all staff that were involved.

And then with that, for your second question, I do really want to disseminate this throughout to other units in our hospital and to other NICUs throughout the country. We hope to publish this on the MedEd portal so that way it can be readily available for other people to use. And then also, you know, publishing it in academic journals as well. So that is our ultimate goal and our ultimate hope.

We would love to meet with more stakeholders in the PICU and ER because we've heard from the residents that they feel like this would be incredibly beneficial to use in those settings as well.

Srirupa (25:28.652)

Yeah, no, absolutely. I think that when we talk about critical events, it should probably cover all of the critical event hotspots, which as we know, ED and PICU included are some of those big hotspots for sure. But this is fantastic research and this is some very good findings that I think would, like you said, would be applicable in so many different units in the country, not just in the US, but like everywhere. So this is fantastic. And I'm so happy and proud that you got this accomplished.

This is wonderful. I always end my sessions by asking you two questions. One, what is one advice that you would give to any incoming fellow who would be interested in your line of research?

Kelsey Kirkman (26:11.959)

I think if you're interested in medical education, find more ways to do teaching and to interact with the learners at your institution, whether that's being a lecturer or working with your program leadership to help develop and improve curriculum for residents and medical students or even for the fellows that rotate through the NICU.

I think you should definitely reach out to your program leadership and figure out who is doing medical education research at your institution so they can hook you up with those people to be able to start to learn more about medical education research and how your ideas could actually turn into real projects.

And then I think some great resources for people that are interested in learning more about medical education research are actually two other podcasts. are ones called Key Lime and one's called Papers. They both are talk about medical education and Papers focuses more on medical education research and Key Lime is more on innovations in medical education, but incredibly, incredibly useful. I learned a lot about

what I know today about medical education research from listening to those podcasts, as well as Dr. Laura Varpio. All of her articles and papers were incredibly valuable and she does a great job teaching and explaining all the different theories and methodologies and approaches to medical education research. So would definitely look into her stuff as well.

Srirupa (27:41.656)

That's awesome. For our listeners, we will try to put all of the resources that Dr. Kirkman had just mentioned now, and we'll kind put it in the description for you all to check them out for anyone who's interested in medical education research. That's some very important and good advice. Thank you so much for that, Kelsey. The last question, I told you two questions. So my second question is, we don't ever realize how time flies and...

Kelsey Kirkman (28:00.908)

you

Srirupa (28:06.104)

I didn't even realize that I'm six months into my first attending job, which also means that you're six months into your fellowship, your final year of fellowship. So where is life taking you next, Kelsey? And where do you see yourself in the next few years?

Kelsey Kirkman (28:10.891)

you

Kelsey Kirkman (28:19.711)

Yeah, so as with all the other third year fellows throughout the country, I'm currently interviewing and awaiting, hopefully offer letters from different institutions so that hopefully I can have a big girl attending job just like you, Rupa. My goal is to work at an academic institution. I, of course, as you can see, love medical education and so I want to work with learners. I want to work with residents and medical students and fellows.

I love to one day, hopefully within five to 10 years, start to work my way into a leadership position, associate program director, or program director role. And I think my master's in education and all of this work that I've done during fellowship has really prepared me to start to work into that area in my career.

Srirupa (29:09.708)

Yeah, and I must say you're going to make a fantastic program director. And I use this term growing roots and I clearly see that you're growing roots to that successful career that you're going to have as a leader in fellowship program. And that is just amazing. I'm really incredibly happy that you were able to make it to share your insights on medical education research, which is such an important area of neonatology and such an important and upcoming area of medical education.

focusing on how you can improve medical education for all of our trainees. So this is fantastic and I appreciate you taking your time to come on the show and talk about that. Thank you so much, Kelsey.

Kelsey Kirkman (29:49.269)

It's my pleasure. Thank you for inviting me, Rupa.

Srirupa (29:52.558)

Alrighty, bye.

Kelsey Kirkman (29:53.985)

Bye.