Discussion

Pediatric emergency care remains a challenging domain for EM trainees, given variability in clinical exposure. In the United States, approximately 30 million children visit emergency departments annually, with more than 80% receiving care in general emergency departments, underscoring the need for pediatric preparedness across diverse clinical settings [11].

While the role of the EM physician in caring for children will continue to expand, EM graduates often report feeling unprepared or apprehensive when managing pediatric patients after completing their residency [12-13]. In one study, EM program directors have also reported lower confidence in their graduating residents’ preparedness to care for pediatric patients compared with adult patients [14].

National commentary on the proposed revisions to the ACGME EM requirements underscores both the increased emphasis on pediatric emergency care training and the ongoing challenges of ensuring adequate clinical encounters, particularly for children under 12 years and neonatal resuscitation, given the variable pediatric patient volumes, uneven access to pediatric centers, and unpredictable case mixes across training sites [15]. This increased focus reflects longstanding evidence that younger pediatric patients, especially neonates and young infants, are among the most anxiety-provoking for EM physicians [16-17]. Recent position statements echo these concerns, calling for practical, flexible approaches and highlighting the need for scalable educational strategies that can reliably supplement limited pediatric exposure [18].

Interactive case-based teaching sessions, such as morning reports, have long served as a model for residency education. When paired with simulation and structured debriefing, these sessions provide immersive practice that translates didactic content into applied clinical reasoning, addressing a common gap caused by sporadic pediatric exposures across training sites. By leveraging existing conference time and minimal equipment, this model provides a feasible and scalable approach to expanding experiential pediatric learning across diverse training environments.

In this study, integration of low-fidelity simulation into morning report was associated with high levels of perceived benefit across multiple domains, with 88-91% of participants reporting improvements in knowledge, comfort, and teamwork. These proportions significantly exceeded a neutral distribution (all p < 0.001), supporting that observed effects were unlikely due to chance. Although high-fidelity simulation may provide greater realism for selected scenarios, low-fidelity approaches have been shown to achieve meaningful educational outcomes when supported by effective case design and debriefing.

Our findings suggest that brief, low-fidelity simulations integrated within the morning report are resource-efficient and perceived as beneficial for reinforcing pediatric competencies. This educational approach is also practical and scalable. Low-fidelity materials were sufficient to facilitate rich discussions and active learning, reducing dependence on simulation center infrastructure and minimizing barriers related to space, faculty availability, and scheduling complexity. These characteristics make the model readily adaptable across diverse EM residency programs, and particularly advantageous for community-based programs without access to high-fidelity simulation facilities, limited access to dedicated pediatric centers, or variable pediatric volumes.

Item-level analysis further demonstrated consistently high agreement across domains such as clinical decision-making, prioritization, communication, and preparedness, with agreement exceeding 50% for all measured items (all p < 0.001). These findings suggest that the educational impact extends beyond general perceptions to specific competencies relevant to pediatric emergency care. This study expands on existing literature by describing the integration of low-fidelity simulation into an existing educational conference structure, rather than as a stand-alone simulation session. Previous studies have examined low-fidelity and in situ simulation in both resource-limited global settings and U.S.-based programs; however, fewer reports have described embedding simulation into routine didactic sessions such as morning report.

Although this curriculum provided repeated exposure to pediatric scenarios over time, it did not employ a formal spaced repetition methodology characterized by structured intervals and deliberate case revisitation. While this curriculum was not designed or evaluated as a spaced-repetition intervention, it highlights a potential framework for future studies examining the effects of structured longitudinal reinforcement. Spaced training has been consistently supported in the medical education literature as an effective strategy to enhance skill acquisition, long-term retention, and transfer of learning compared with massed practice. Systematic reviews of simulation-based spaced education demonstrate improved learning and retention, particularly for procedural and high-acuity skills [19], and prospective cohort data further support sustained gains in knowledge retention with spaced approaches [20].

The recurring nature of these sessions suggests a potential opportunity to incorporate spaced-repetition principles in future curriculum development, although this hypothesis was not directly evaluated in the present study. Even without formal spacing, repeated reinforcement of pediatric concepts aligns with evidence demonstrating improvements in learner engagement, confidence, and retention [21]. Embedding these sessions within routine educational conferences also provides a psychologically safe environment to rehearse high-acuity, low-frequency skills that are particularly vulnerable to decay.

Limitations

This study has several limitations. As a single-site implementation within an academic EM residency, generalizability may be limited. Outcomes were based on self-reported survey data and are therefore subject to response bias. The survey instrument was locally developed and not previously validated. No objective measures of knowledge acquisition, clinical performance, or long-term retention were collected, limiting assessment to learner perceptions. Because attendance was not formally tracked for each session, precise participation rates could not be determined, and the potential for selection bias cannot be excluded.

Additionally, session frequency varied over the study period, with 27 sessions conducted over 45 months, reflecting competing curricular demands rather than a standardized delivery schedule. Formal feasibility outcomes, including implementation time, faculty workload, and cost analyses, were not collected. Feasibility was assessed descriptively based on successful integration into existing conference time using minimal educational resources. Furthermore, while statistically significant improvements in perceived outcomes were observed, these findings reflect self-reported measures rather than objective performance outcomes.

Implementation of this curriculum relied on an established morning report structure with protected educational time, which may not be available in all training environments, and sessions were facilitated by PEM-trained faculty, which may limit reproducibility in programs without subspecialty expertise. However, use of standardized, publicly available case resources may support adaptation by general EM faculty when paired with structured facilitation and debriefing.

Future direction

Future work should incorporate objective outcome measures, including assessments of critical actions, simulation-based performance metrics, pre- and post-intervention knowledge testing, and evaluation of long-term retention and transfer to clinical practice. In addition, future steps should explore whether integration of structured spacing or longitudinal reinforcement further enhances statistically significant improvements in learner outcomes.