Academic Pediatrics

Instructions for Authors

2012-05-01

Effective January 2012, the journal now requires all authors to complete the ICMJE conflict of interest form (available at http://www.icmje.org/coi_disclosure.pdf) and to upload these forms on the editorial website at the end of all new manuscript submissions.

Making Informed Policy Decisions About Newborn Hearing Screening

Alex R. Kemper, Stephen M. Downs — 2012-05-01

In this issue of Academic Pediatrics, Colgan et al present the results of a systematic review to evaluate the cost-effectiveness of newborn screening for bilateral permanent congenital hearing impairment. Despite the significant investment in universal newborn hearing screening, they found little information is available about its cost-effectiveness compared with risk-based assessment. Their methods are rigorous, and the findings raise important questions about the value of newborn hearing screening and why so few health economic analyses have been recently conducted.

Development of an Algorithm for the Diagnosis of Otitis Media

Kenneth M. McConnochie — 2012-04-13

Looking back 100 years from now, how will you judge the professional integrity of medicine in the second decade of the 21st century, more than 8 decades after Fleming discovered penicillin? Among young children, acute otitis media (AOM) has been the most frequent diagnosis for which antibiotics are prescribed. The diagnosis and management of AOM should provide a telling case study. You assume medicine had long ago mastered the treatment of AOM and persistent middle ear effusion, two of the most common acute and chronic conditions encountered in primary care settings. Indeed, society accords professional status on the basis of trust that such mastery exists and is unique to the profession.

And How Are the Children?

Ruth A. Etzel — 2012-05-01

In East Africa, when Masai warriors met one another, the traditional greeting was “Kasserian ingera,” which means “and how are the children?” It is relevant for pediatricians to ask ourselves this question with regard to the world's children. In an era of increasing industrialization, globalization, and sophisticated health care technologies, progress on improving indicators of children's health has been uneven. Global statistics reveal that in 2010, approximately 7.6 million children died before their 5th birthday. We are far from meeting the goal set by the world leaders who assembled in 1990 to set development goals for the new millennium, to reduce by two thirds, between 1990 and 2015, the mortality rate of children younger than 5. Most of the deaths of children younger than 5 result from only 5 conditions—acute respiratory infections, diarrhea, malaria, measles, and malnutrition—or a combination of these conditions. These 5 conditions are responsible for approximately 83% of outpatient consultations. Yet more than two-thirds of the early deaths in children could be prevented or treated with access to simple, affordable interventions, including exclusive breastfeeding, safe water, adequate sanitation and hygiene, insecticide-treated bed nets, and vaccination. These interventions are best implemented at the community level.

Obese and Hungry in the Suburbs: The Hidden Faces of Food Insecurity

Jennifer A. O’Malley, Christopher B. Peltier, Melissa D. Klein — 2012-05-01

What is it about those last 30 minutes of clinic?… Our last 2 patients of the day had just registered when I caught a glimpse of a husky, sulking teenage boy shuffling into examination room 2. It was the end of a long and busy day that had been filled with back-to-school checkups, and a smattering of minor “back-to-sports” injuries. Handing me a thin paper chart and keeping a thicker, dog-eared one for himself, my preceptor cheerfully said “OK, time to divide and conquer… I’ll take the older brother, Sam, why don’t you see the younger kiddo, Xavier, in room 3 with his mom, Mrs. Thompson? Just a quick checkup, and don’t forget to ask about a flu shot!”

The Association of Pediatric Program Directors: The First 25 Years

Kenneth B. Roberts, Laura E. Degnon, Robert S. McGregor — 2012-04-13

In the early 1970s, the American Board of Pediatrics (ABP) had no mechanism for communicating with directors of the more than 200 residency programs. Communication existed between the ABP and the medical school department chairs through the Association of Medical School Pediatric Department Chairs (AMSPDC), but this mechanism did not extend to the numerous nonuniversity programs. Between 1974 and 1982, the ABP sponsored 4 conferences for program directors. At the meeting in 1978, the feasibility of forming an association of program directors was raised, with particular interest expressed by individuals in nonuniversity programs, and, in 1983, the ABP Program Directors Liaison Committee recommended to the ABP leadership that a program directors' association be formed. ABP leaders presented the idea to their counterparts in AMSPDC and the American Academy of Pediatrics (AAP). Two individuals who deserve special mention are Robert Brownlee and Robert Holm. Dr. Brownlee was the Executive Secretary of the ABP (a position later renamed President and Chief Executive Officer). Before coming to the ABP in 1975, he had been in practice in Greenville, South Carolina, and, in 1971, had started a residency program there, which he directed. Dr. Holm also had been in practice before directing a nonuniversity residency program. He was the Michigan chapter chair for the AAP and solicited AAP support to represent nonuniversity programs.

The Cost-Effectiveness of Universal Newborn Screening for Bilateral Permanent Congenital Hearing Impairment: Systematic Review

2012-05-01

Abstract: Objective: Universal newborn hearing screening for bilateral permanent congenital hearing impairment is standard practice in many developed economies, but until there is clear evidence of cost-effectiveness, it remains a controversial use of limited health care resources. We conducted a formal systematic review of studies of newborn hearing screening that considered both costs and outcomes to produce a summary of the available evidence and to determine whether there was a need for further research.Methods: A search was conducted of medical and nursing databases and gray literature websites by the use of multiple keywords. The titles and abstracts of studies were examined for preliminary inclusion if reference was made to newborn hearing screening, and to both costs and outcomes. Studies of potential relevance were independently assessed by 2 health economists for final inclusion in the review. Studies that met inclusion criteria were appraised by the use of existing guidelines for observational studies, economic evaluations and decision analytic models, and reported in a narrative literature review.Results: There were 22 distinct observational or modeled evaluations of which only 2 clearly compared universal newborn hearing screening to risk factor screening for bilateral permanent congenital hearing impairment. Of these, the single evaluation that examined long-term costs and outcomes found that universal newborn hearing screening could be cost-saving if early intervention led to a substantial reduction in future treatment costs and productivity losses.Conclusions: There are only a small number of economic evaluations that have examined the long-term cost-effectiveness of universal newborn hearing screening. This is partly attributable to ongoing uncertainty about the benefits gained from the early detection and treatment of bilateral permanent congenital hearing impairment. There is a clear need for further research on long-term costs and outcomes to establish the cost-effectiveness of universal newborn hearing screening in relation to other approaches to screening, and to establish whether it is a good long term investment.

Employment, Family Leave, and Parents of Newborns or Seriously Ill Children

2012-03-29

Abstract: Objectives: Parents of newborns and children with special health care needs (CSHCN) often experience conflict between employment and family responsibilities. Family leave benefits such as the federal Family and Medical Leave Act and California’s Paid Family Leave Insurance program help employed parents miss work to bond with a newborn or care for an ill child. The use of these benefits, however, is rare among mothers of CSHCN and fathers in general and limited even among mothers of newborns. We explored barriers to and experiences with leave-taking among parents of newborns and CSHCN.Methods: We conducted semistructured qualitative interviews in 2008 with 10 mothers and 10 fathers of newborns and 10 mothers and 10 fathers of CSHCN in Los Angeles to explore their need for and experiences with family leave. Qualitative analytical techniques were used to identify themes in the transcripts.Results: All parents reported difficulties in accessing and using benefits, including lack of knowledge by employers, complexity of rules and processes, and inadequacy of the benefits themselves. Parents of CSHCN also described being too overwhelmed to rapidly seek and process information in the setting of urgent and often unexpected health crises. Most parents expressed a clear desire for expert guidance and saw hospitals and clinics as potentially important providers.Conclusions: Even when parents are aware of family leave options, substantial barriers prevent many, especially parents of CSHCN, from learning about or applying for benefits. Clinics and hospitals might be opportune settings to reach vulnerable parents at times of need.

Inter-Agency Collaboration in the Care of Children with Complex Chronic Conditions

2012-05-01

Abstract: Objectives: The purpose of this article was to describe the network of collaboration among agencies that serve children with complex chronic conditions (CCCs) and identify gaps in the network.Methods: We surveyed representatives from agencies that serve children with CCCs in Forsyth County, North Carolina, about their agencies’ existing and desired collaborations with other agencies in the network. We used Social Network Analytical (SNA) methods to describe gaps in the network. Mean out-degree and in-degree centrality (number of collaborative ties extending from or directed toward an agency) and density (ratio of extant ties to all possible ties) were measured.Results: In this network with 3658 possible collaborative ties, care-coordination agencies and pediatric practices reported the highest existing collaborations with other agencies (out-degree centrality: 32 and 30, respectively). Pediatric practices reported strong ties with subspecialty clinics (density: 73%), but weak ties with family support services (density: 3%). Pediatric practices and subspecialty clinics (in-degree: 26) received the highest collaborative ties from other agencies. Support services and durable medical equipment (DME) companies reported low ties with other agencies (out-degree: 7 and 10, respectively). Nursing agencies reported the highest desired collaborations (out-degree: 18). Support services, pediatric practices, and care-coordination programs had the highest in-degree centrality (7, 6, and 6, respectively) for desired collaborations. Nursing agencies and support services had the greatest gaps in collaboration.Conclusion: Although collaboration exists among agencies serving children with CCCs, there are many gaps in the network. Future studies should explore barriers and facilitators to inter-agency collaborations and whether increased collaboration in the network improves patient-level outcomes.

Predictors of Parental Posttraumatic Stress Disorder Symptoms in the Year After Adolescent Traumatic Injury

2012-04-05

Abstract: Objectives: Parental posttraumatic stress disorder (PTSD) is common after pediatric traumatic injury and may negatively impact parental functioning and quality of life during this key period of the child’s early postinjury recovery. This study aimed to evaluate the course and predictors of PTSD in parents during the year after an adolescent traumatic injury.Methods: This prospective cohort study included a population-based sample of 99 parent-adolescent dyads. Assessment was through structured interview administration of standardized measures. Interviews were conducted within 30 days of injury and 2, 5, and 12 months after injury. Mixed model regression was used to evaluate variables potentially associated with repeated measures of parental PTSD symptoms at the follow-up time points.Results: Twenty-three percent of parents met symptomatic criteria for PTSD at the first postinjury evaluation, as did 15% at 2 months, 7% at 5 months, and 6% at 12 months after the injury. The percentage of parents meeting symptomatic PTSD criteria decreased significantly between the 2-month and 12-month evaluations. Mixed-model regression analyses revealed greater PTSD symptoms within 30 days of injury and a greater number of postinjury parental traumatic and/or stressful life events as significant predictors of parental PTSD. Adolescent factors did not affect the risk of parental PTSD.Conclusions: A substantial subgroup of parents demonstrate high PTSD symptom levels during the course of the year after an adolescent injury. Given that early modifiable risk factors can be identified, future investigations focusing on screening and intervention are warranted.

Factors Distinguishing Youth Who Report Self-Injurious Behavior: A Population-Based Sample

2012-03-19

Abstract: Objective: To identify factors distinguishing adolescents across 3 groups: no self-harm, nonsuicidal self-injury (NSSI) only, and NSSI and suicide attempt (NSSI + SA).Methods: Data were from the 2007 Minnesota Student Survey. The sample included 61,330 students in grades 9 and 12. Logistic regression analysis determined factors that best distinguished adolescents who reported NSSI from those who reported no self-harm, and adolescents who reported NSSI + SA. Final models were developed over 3 stages of analysis that tested the importance of variables within risk factor, protective factor, and co-occurring health-risk behavior domains.Results: For male and female subjects, factors that consistently distinguished youth who reported NSSI from those who reported no self-harm included depressive symptoms, hopelessness, physical abuse, less parent connectedness, running away from home, and maladaptive dieting behavior. Factors that distinguished the NSSI + SA group from the NSSI only group for both sexes were a mental health problem, depressive symptoms, hopelessness, physical abuse, and running away from home. Other factors, such as sexual abuse, were significant in models for males or females only. Hopelessness constituted the leading factor to increase the likelihood that youth who self-injured also attempted suicide.Conclusions: Youth engaging in NSSI experience diverse psychosocial stressors and significant distress. Clinicians and school personnel are well-positioned to offer support to these youth. Furthermore, they can help address NSSI among youth by identifying those who self-injure early, assessing for hopelessness and suicidality, facilitating connections to prosocial adults, addressing maladaptive dieting behavior, and supporting runaway youth.

Development of an Algorithm for the Diagnosis of Otitis Media

Nader Shaikh, Alejandro Hoberman, Howard E. Rockette, Marcia Kurs-Lasky — 2012-03-29

Abstract: Background: The relative importance of signs and symptoms in the diagnosis of otitis media has not been adequately evaluated. This has led to a large degree of variation in the criteria used to diagnose otitis media, which has resulted in inconsistencies in clinical care and discrepant research findings.Methods: A group of experienced otoscopists examined children presenting for primary care. We investigated the signs and symptoms that these otoscopists used to distinguish acute otitis media (AOM), otitis media with effusion (OME), and no effusion. We used recursive partitioning to develop a diagnostic algorithm. To assess the algorithm, we validated it in an independent dataset.Results: Bulging of the tympanic membrane (TM) was the main finding that otoscopists used to discriminate AOM from OME; information regarding the presence or absence of other signs and symptoms added little to the diagnostic process. Overall, 92% of children with AOM had a bulging TM compared with 0% of children with OME. Opacification and/or an air-fluid level was the main finding that the otoscopists used to discriminate OME from no effusion; 97% of children diagnosed with OME had an opaque TM compared with 5% of children diagnosed with no effusion. An algorithm that used bulging and opacification of the TM correctly classified 99% of ears in an independent dataset.Conclusions: Bulging of the TM was the finding that best discriminated AOM from OME. The algorithm developed here may prove to be useful in clinical care, research, and education concerning otitis media.

Application of Classic Utilities to Published Pediatric Cost-Utility Studies

S. Maria E. Finnell, Aaron E. Carroll, Stephen M. Downs — 2011-11-11

Abstract: Objective: Economic analyses, such as cost-utility analyses (CUAs), are dependent on the quality of the data used. Our objective was to test how health utility values (measurements of patient preference) assessed by recommended methods (classic utilities) would impact the conclusions in published pediatric CUAs.Methods: Classic utilities for pediatric health states were obtained by recommended utility assessment methods, time trade-off, and standard gamble in 4016 parent interviews. To test the impact of these utilities on published studies, we obtained a sample of published pediatric CUAs by searching Medline, EMBASE, EconLit, Health Technology Assessment Database, Cochrane Database on Systematic Reviews, Database of Abstracts of Reviews of Effects, and the Cost Effective Analysis (CEA) Registry at Tufts Medical Center, using search terms for cost-utility analysis. Articles were included when results were presented as cost per quality adjusted life-years (QALYs), the interventions were for children <18 years of age and included at least one of the following health states: attention deficit hyperactivity disorder, asthma, gastroenteritis, hearing loss, mental retardation, otitis media, seizure disorder, or vision loss. Studies that did not include these or equivalent health states were excluded. For each CUA, we determined utilities (values for patient preference), the utility assessment method used, and presence of one-way sensitivity analyses (SAs) on utilities. When one-way SAs were conducted, we determined if using our classic utilities would change the result of the CUA. When an SA was not presented, we determined if using our classic utilities would tend to support or not support the published conclusions.Results: We evaluated 39 articles. Eighteen articles presented results of one-way SAs on utilities. Seven articles presented SAs over a range that included our classic utilities. In 4 of the 7, using classic utilities would change the conclusion of the study. For the 32 articles where no one-way SA were presented (n = 21), or where the classic utilities fell outside the range tested (n =11), a change to classic utility would tend against the study conclusion in 12 articles (31%).Conclusions: More than a third of published CUA studies could change if pediatric utilities obtained by recommended, classic methods were used. One-way SAs on utilities are often not presented, making comparison between studies challenging.

A Proposed Model Curriculum in Global Child Health for Pediatric Residents

2012-04-09

Abstract: Objective: In response to the increasing engagement in global health (GH) among pediatric residents and faculty, academic GH training opportunities are growing rapidly in scale and number. However, consensus to guide residency programs regarding best practice guidelines or model curricula has not been established. We aimed to highlight critical components of well-established GH tracks and develop a model curriculum in GH for pediatric residency programs.Methods: We identified 43 existing formal GH curricula offered by U.S. pediatric residency programs in April 2011 and selected 8 programs with GH tracks on the basis of our inclusion criteria. A working group composed of the directors of these GH tracks, medical educators, and trainees and faculty with GH experience collaborated to develop a consensus model curriculum, which included GH core topics, learning modalities, and approaches to evaluation within the framework of the competencies for residency education outlined by the Accreditation Council for Graduate Medical Education.Results: Common curricular components among the identified GH tracks included didactics in various topics of global child health, domestic and international field experiences, completion of a scholarly project, and mentorship. The proposed model curriculum identifies strengths of established pediatric GH tracks and uses competency-based learning objectives.Conclusions: This proposed pediatric GH curriculum based on lessons learned by directors of established GH residency tracks will support residency programs in creating and sustaining successful programs in GH education. The curriculum can be adapted to fit the needs of various programs, depending on their resources and focus areas. Evaluation outcomes need to be standardized so that the impact of this curriculum can be effectively measured.

Global Health Training in Pediatric Residency: A Qualitative Analysis of Faculty Director Insights

Monica Eneriz-Wiemer, Brett D. Nelson, Janine Bruce, Lisa J. Chamberlain — 2012-04-16

Abstract: Objective: Interest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.Methods: Seven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.Results: All programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.Conclusions: Directors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.

International Electives at the University of Minnesota Global Pediatric Residency Program: Opportunities for Education in All Accreditation Council for Graduate Medical Education Competencies

2012-04-09

Abstract: Purpose: Globally competent pediatricians are in demand because of the increasing numbers of children from immigrant families living in the United States and the shortages of health care workers in low-income countries where the majority of the worlds' children live. This study sought to better understand the educational outcomes of international electives taken by pediatric residents training in global health.Methods: Thirty-two pediatric residents who participated in an international elective as part of a global health curriculum completed reflective essays which were analyzed for themes from 2006 to 2010. During the first-order analysis, the emergent themes mapped to the Accreditation Council for Graduate Medical Education (ACGME) competencies. In response, a second-order analysis re-examined the essays with an additional researcher to support categorization consistent with the ACGME competencies.Results: More than 90% of essays described experiences related to medical knowledge, patient care and systems-based practice. More than 50% included reflections on practice-based learning and improvement, professionalism, and interpersonal and communication skills. Residents also described the impact on their personal and professional development.Conclusion: International electives can provide educational opportunities for residents to develop competency in each of the 6 ACGME domains and to reevaluate their life purpose and career goals. In addition to opportunities to increase their medical knowledge, patient care and communication skills, residents find international electives rich learning environments for systems-based practice, practice-based learning/improvement, and professionalism, domains that can be challenging to teach. These findings support the importance of international electives in global health in meeting core requirements in residency training.

What are Residents Learning at Night? A Qualitative and Quantitative Assessment of Resident Self-Identified Learning Themes

Jessica Myers, Anna Lin, Erin Augustine, Liane Campbell, Rebecca Blankenburg — 2012-05-01

Nighttime rotations bring a unique challenge for providing the teaching that was previously available during daytime conferences and rounds. In order to improve nighttime education, many educators have wondered what residents actually learn at night and how to best capture these learning experiences, especially in the context of the new work hours.

Teaching and Evaluating Communication and Professionalism Across Pediatric Critical Care Medicine Fellowships

2012-05-01

Communication and professionalism are crucial elements of graduate medical education, but teaching and evaluating these two areas are often challenging. Despite their importance, little is known regarding the teaching and evaluation modalities utilized by pediatric critical care medicine (PCCM) programs. We hypothesized that teaching and evaluation techniques for communication and professionalism are diverse among PCCM training programs.

How Well Do Pediatric Critical Care Fellowship Programs Comply With Acgme Requirements for Teaching Professionalism and Communication?

2012-05-01

Communication and professionalism are key educational competencies established by the ACGME that include a number of required content areas. These competencies are often difficult to teach, and little data exist regarding whether training programs provide formal instruction in all mandatory areas. We hypothesized that many pediatric critical care medicine (PCCM) programs lack a structured method to teach required elements of communication and professionalism.

Addressing The New Mental Health Competencies

Susan Bostwick, Cori Green, Elisa Hampton — 2012-05-01

1 in 5 children suffer from a mental health (MH) problem; 50% seek services; 25% receive them. Pediatricians need to address MH issues, yet are not adequately trained to do so. The American Academy of Pediatrics (AAP) recommended new MH competencies for all pediatricians in 2010.

Predicting Board Performance in Pediatrics

Kimberly A. Boland, Tara McKinley, Keith P. Cross, Michelle D. Stevenson — 2012-05-01

Early identification of trainees at risk for board failure may allow for prompt effective intervention. The utility of in-training exam (ITE) and USMLE Step 1 and 2 score thresholds in predicting board performance has not been well defined.

Creation of a Learning Goal Scoring Rubric

Tai M. Lockspeiser, Adam A. Rosenberg, Patricia Schmitter, J. Lindsey Lane — 2012-05-01

Creation of learning goals is an essential component of life-long learning. In order to be effective, learning goals (LGs) must be well crafted. No tool currently exists to assess the quality of LGs.

“Bucking the Norms”: Resident Perceptions of a Longitudinal Block Experience

Tai M. Lockspeiser, J. Lindsey Lane — 2012-05-01

One month rotations with curricular content and patient exposure that is generally not directly determined by a resident’s career goals is the norm for pediatric residency training. In contrast, at the University of Colorado, we have implemented a 4-month Longitudinal Block (LB) where residents individualize clinical experiences based on their career path. The experience includes individualized learning goals, mentoring, direct observation, group seminars, and customized clinical experiences.

Use of Wiki-Based Technology to Document Resident-Driven QI Projects

Glenn Rosenbluth, Natalie Burman, Elizabeth R. Hanson, Katie E. McPeak — 2012-05-01

Wiki-based technology has come into widespread use in the last decade. It provides an opportunity for individuals to update a webpage which is then shared with either a select group or all users. Our objectives were (1) to determine the technical feasibility of implementing wiki sites for documentation of UCSF pediatrics residents’ continuity clinic-based QI projects; and (2) to document adoption of this technology by residents and faculty.

End of Life Education for Pediatric Residents During a Pediatric Intensive Care Rotation

2012-05-01

The aim of this study was to provide training to pediatric residents in end of life (EOL) care and to better prepare them to communicate with parents in difficult situations. 8 PL-2 residents participated in an EOL curriculum comprised of didactic lectures and small group discussions. Topics included communication skills, pain management and discussing end of life with families. 9 PL-3 residents did not receive the curriculum during the study and served as the control group. Pre- and postsurveys on confidence levels were completed by all residents. Both groups participated in an objective structured clinical exam (OSCE) with the following scenarios: an end of life discussion, withdrawal of mechanical ventilation and pain management in an adolescent. Encounters were video recorded and resident performance was evaluated by five observers using a checklist for each scenario. Analysis included: 1) paired t-test to assess the change in the level of confidence, 2) independent t-test to assess OSCE ratings performance differences between control and intervention group.

The Effects of a Day/Night Shift System on Intern Sleep, Work Load, and Conference Attendance

2012-05-01

The ACGME regulations limit interns to 16 continuous duty hours beginning July 1, 2011. The impact of this rule on sleep, work load, and conference attendance is unknown. To conduct a trial of a ward shift system compliant with the 2011 ACGME regulations and to compare sleep time, sleep quality, patient load, hours worked, and conference attendance with a q 4 call schedule.

Does a Neonatal Night Shift Team Increase Housestaff Exposure to Resuscitations?

2012-05-01

Given ACGME duty hour changes, pediatric residency programs have changed from call to shift systems. These changes may pose challenges in preserving high quality resident education and providing sufficient patient exposure. We hypothesized that a night shift system would increase exposure to neonatal resuscitations and enhance housestaff education.

The New Era of Nighttime Education: What Do Residents Want?

2012-05-01

The 2011 ACGME work hour changes resulted in a substantial increase in pediatric nighttime rotations. Nighttime rotations bring the unique challenge of delivering resident education, traditionally provided by daytime conferences and rounds. As programs balance the new ACGME regulations with educational goals, it is vital to understand residents’ attitudes toward nighttime teaching.

Identifying Gaps Between Faculty and Resident Expectations of Resident Autonomy

2012-05-01

With the advent of work hours restrictions and generational changes in residents, the culture of residency is shifting. Residents are regaled with faculty anecdotes, “When I was a resident…,” and faculty members are frustrated by residents who seem to have different educational expectations and priorities. This subjective evidence suggests a cultural divide, but there are few evidence-based reports to substantiate or clarify areas of divergence.

State of Medical Home Education in Pediatric Residency Programs

Aditee P. Narayan, Renee M. Turchi, Michelle Z. Esquivel, Umbereen S. Nehal — 2012-05-01

The US Dept of Health and Human Services, via Healthy People 2020 (HP 2020), identifies health goals for the coming decade. One goal is fostering medical homes that are family-centered, culturally-competent, comprehensive, coordinated systems for all children, including those with special health needs. To achieve this goal, physicians must understand the medical home, beginning in training. A workgroup comprised of members from the AAP, National Center for Medical Home Implementation, APPD, APA, residents, national experts and families was established to create a flexible, standardized medical home curriculum for training programs. We conducted a needs assessment on the current state of medical home education in pediatric programs.

Shortening Resident Duty Hours - Does It Shortchange Student Learning?

Christin M. Traba, David J. Cennimo, Roger A. Rivera, Susan G. Mautone — 2012-05-01

Recent attention has focused on change in resident duty hours as it pertains to resident education and patient safety, but there are no published data on the impact of these changes on medical student performance and mixed data on the impact on student perceptions during third-year clerkships. In July 2004, 24-hour call was completely eliminated from the UMDNJ-New Jersey Medical School pediatric residency program. We analyze the effects of this change in resident duty hours on medical students’ performance and perceptions in the pediatric clerkship.

Nighttime Resident Education Pilot: A Standardized, Web-Based Curriculum

Anna Lin, Erin Augustine, Liane Campbell, Jessica Myers, Rebecca Blankenburg — 2012-05-01

With the 2011 ACGME resident work hour restrictions, there has been a substantial increase in the number of nighttime rotations in pediatric residency programs. Because of the increase of these rotations, nighttime education must be optimized for residents who miss daily didactic sessions such as morning report and noon conference.

Lack of Predictive Value of Letters of Recommendation: An Exercise in Futility

Teri L. Turner, Mark A. Ward, Anne C. Gill — 2012-05-01

Residency programs attempt to select the best residency candidates among applicants to their programs. Criteria commonly used in making the selection include personality, communication skills, medical school grades and performance, United States Medical Licensing Examination scores, Dean’s letters, and letters of recommendation (LORs).

Physician Know Thy Learners: A 5-Year Description of Learning Styles Across the Generations

Teri L. Turner, Satid Thammasitboon, Mark A. Ward — 2012-05-01

Much has been written about learning styles. However, less attention has been given to intergenerational differences in those styles. To describe the learning preferences of residents over a five year period spanning two generational cohorts and to compare and contrast learning style preferences based on demographic and performance variables.

Learning Styles and Concept Mapping: The Chicken or The Egg

Teri L. Turner, William B. Cutrer — 2012-05-01

Individuals have unique and varied learning styles and prefer to organize information in different ways. The use of Concept Mapping has demonstrated the ability to enable deeper and more meaningful learning. Meaningful learning is required to transition from novice to master clinician.

New Professionalism Challenges in Medical Training: An Exploration of Social Networking

2012-05-01

The practice of medicine in the new millennium is enhanced by innovative technology that yields unprecedented speed of communication but may also present new risks for unprofessional behavior. We conducted a survey to determine program directors’ perceptions and experiences with residents’ use of social networking sites (SNS).

Comparison of Institutional Coverage Models in the Era of Duty Hour Restrictions

2012-05-01

Compliance with 2011 Common Program Requirements necessitated that programs revise coverage models. Quality resident education and patient care must continue within increased time constraints. Limited evidence exists regarding the most effective model to address these concerns.

A Prospective Randomized Trial of the Effectiveness of Lumbar Puncture Simulation Training in Pediatric Residents

2012-05-01

There is a clear emphasis on “real and/or simulated training” of procedures in the proposed ACGME program requirements for pediatrics. Recent evidence has shown a formal curriculum of patient simulation training could improve resident competency in core procedural skills. However, studies are needed to determine if pediatric procedural simulation training results in improved real patient performance.

E-Learning Software to Enhance Pediatric Medical Education

Ryan Bode, Dawn S. Barcellona, Karen Scharlatt, Blake Bulloch, Grace Caputo — 2012-05-01

Medical educators face many challenges in teaching future physicians. Resident duty hour reform has resulted in a potential decline in teaching opportunities. E-learning technologies offer trainees flexibility and the ability to tailor their experiences to meet their personal objectives.

Teaching Residents to “Teach-Back”: Does a Structured Curriculum Including Simulation Improve Pediatric Resident Communication Skills?

2012-05-01

Health literacy awareness and improved communication have been identified as key factors that may reduce hospital re-admission rates, and increase both patient satisfaction and patient outcomes. Recent studies have confirmed that lack of attention to context of care can lead to medical errors. The ACGME requires programs to teach and assess these skills in our residents. This study is a pre-post design to assess the efficacy of a multi-modal educational intervention to improve the communication skills of pediatric residents specifically in the areas of context of care and performing “teach-back” in their encounters. First year pediatrics and combined medicine-pediatrics residents (n=25) participated in a structured simulation session with standardized patients with a case of a child with a complex psycho-social history. Videos of the sessions were reviewed and scored by 2 faculty members and a social work supervisor. Discrepancies in the scoring were resolved with a majority rule. Evaluators’ checklists were modified from validated tools4 to assess contextual factors and the use of “teach-back”. Residents were presented with their individual feedback from their session and participated in a group feedback session that focused on “teach-back” and context of care. Each resident then participated in a follow-up simulation session, which was scored using the same methods as the first session. There was a significant increase in use of “teach-back” (p<.001), with 2/25 residents doing “teach-back” at initial session and 17/25 residents doing “teach-back” at follow-up session. An increase was also noted in questions related to the patient’s ability to obtain the medications prescribed at the visit. 12/25 residents asked this in the initial session and 24/25 asked in the follow-up session (p=.002). A structured curriculum including simulation may be a useful educational modality for improving communication skills in pediatric residents.

Post Discharge Phone-Call Improves Asthma Care for Inner City Pediatric Patients

2012-05-01

Following hospitalization for asthma exacerbations, children with public health insurance are less likely to fill their prescriptions and more likely to utilize the emergency room. Readmission rates for asthma are higher among children on Medicaid, of a racial minority, or in crowded housing conditions and in poverty. Given its significant morbidity, addressing the problem of racial and socioeconomic disparities in asthma outcomes is a priority.

A Quality Improvement Initiative to Increase Nursing Attendance on Pediatric Hospitalist Family Centered Rounds

Elena Aragona, Jose Ponce Rios, Priya Garg, Elisabeth Schainker, Julia Aquino — 2012-05-01

The AAP states that family-centered care is built upon collaboration between patients, families, and a multidisciplinary team. Nurses are an integral component of the team but are frequently absent from rounds at our institution.

Improving Continuity Care Clinic Flow & Efficiency: A Resident Quality Improvement Project

2012-05-01

Continuity care clinics (CCC) provide important longitudinal care experience for pediatric residents; ACGME requires a minimum one half-day CCC session/week for a minimum 36 outpatient clinic weeks/year. In CCC, residents assume responsibility of care for a progressive number of well patients & those with complex/chronic problems on a regular, continuing basis. To develop proficiency in comprehensive care, the flow & efficiency of the clinic experience is vital. As second-year residents, we addressed communication related to immunization ordering/administration in our CCC as a targeted intervention to improve clinic flow & efficiency. A root cause analysis of multiple factors related to increased clinic length of stay (LOS) identified that CCC nurses did not have a definitive indicator of the end of a patient visit. Our aim statement was: The CCC will improve communication between residents and nurses involving patient immunization hand-off, resulting in an average decreased LOS of 10 minutes (defined at time of check-in to time of discharge) within 3 months of the intervention. LOS data were collected from the electronic medical record during pre- and post-intervention periods. Interventions included: 1) immunization orders left on clipboard in patient room for nurse to collect; 2) immunization orders not placed until attending reviewed; 3) nurses assigned to patient upon review of orders. A histogram graph of LOS duration over time showed mean LOS decreased from 2:15 hours pre-intervention to 1:45 hours post-intervention, with skewing of histogram bars toward a decreased LOS. A control chart of LOS during intervention had a high average LOS of 2:01 hours & a minimum average LOS of 1:45 hours post-intervention, for a total 16 minute decrease in average LOS. Residents learned to understand how nursing processes impact LOS. Focusing on improved resident/nurse communication around immunization ordering & administration allowed LOS to be significantly reduced following this intervention. Continued focus on communication, monitoring of LOS and a continued QI resident project will sustain improvement.

Improving the Rate of Vitamin D Supplementation in Infants

Melissa D. Garganta, April Buchanan — 2012-05-01

The 2008 AAP Guidelines for Vitamin (Vit) D supplementation that all infants consuming less than 1L of Vit D fortified formula daily receive supplementation with at least 400 IU of Vit D daily, beginning in the first days of life are not followed in the pediatric clinic.

Bundled Clinic-Based Intervention Improved 2-Dose Flu Vaccine Compliance

Emily M. McElveen, Daniel Adams — 2012-05-01

Over 200,000 patients are hospitalized annually for influenza-related illness; kids are more vulnerable than healthy adults. Vaccination is the best prevention. Thus, the CDC recommends annual flu vaccination for all children aged 6 months through 18 years of age, with specific guidance that previously unimmunized children aged 6 months through 8 years should receive a 2-dose vaccine series during their first season of flu vaccination. Prior research demonstrates that while two doses of vaccine decreased the number of office visits for influenza-like illness (ILI), one dose of vaccine had no effect on visits for ILI. Average national compliance with the 2-dose recommendation is less than ideal. A retrospective analysis estimated 37% overall compliance. The aim of this project was to design a clinic-based intervention to improve observance of the 2-dose flu vaccine recommendation for patients less than 2 years of age. The bundled intervention included provider education, reminder cards, and phone call reminders. The provider education session reiterated the flu vaccination recommendations, specifically the 2-dose recommendation. The reminder cards were given to patients’ families at the time of their initial vaccination indicating the need for a second immunization in one month’s time. Finally, families were called at least 1 month after administration of their initial flu vaccine to remind them of the need for a second dose. The E-immune immunization database was used to analyze the 2-dose vaccine compliance rates for patients less than 2 years old who received their first flu vaccine from October 2010 - February 2011. Our clinic population’s compliance initially mirrored the national population at 37.5%. There was a statistically significant improvement in the 2-dose vaccine compliance rate after implementation of the bundled intervention (53.8%, p<0.005). This process improvement project demonstrated that a clinic-based, bundled intervention comprised of physician education, reminder notes, and phone follow-up produced a statistically significant improvement in the 2-dose flu vaccine compliance rate for children less than 2 years old.

Accelerating CSF to Lab in Neonatal Fever Workups

2012-05-01

To decrease the length of time from trainee signing up to see patient until cerebrospinal fluid (CSF) arrival in lab during septic workups of the febrile infant under 90 days of age.

Decreasing Cycle Time in a Multi-Disciplinary Clinic

2012-05-01

Multidisciplinary clinics optimize multiple provider-patient interactions, but can cause longer visits. Decrease total cycle time in a multi-disciplinary clinic by 10% from March-December 2011.

Editorial Board

2012-05-01

Editor-in-Chief Peter G. Szilagyi, MD, MPH

2012-05-01

Editor-in-Chief Peter G. Szilagyi, MD, MPH

Academic Pediatrics

Instructions for Authors

Making Informed Policy Decisions About Newborn Hearing Screening

Development of an Algorithm for the Diagnosis of Otitis Media

And How Are the Children?

Obese and Hungry in the Suburbs: The Hidden Faces of Food Insecurity

The Association of Pediatric Program Directors: The First 25 Years

The Cost-Effectiveness of Universal Newborn Screening for Bilateral Permanent Congenital Hearing Impairment: Systematic Review

Employment, Family Leave, and Parents of Newborns or Seriously Ill Children

Inter-Agency Collaboration in the Care of Children with Complex Chronic Conditions

Predictors of Parental Posttraumatic Stress Disorder Symptoms in the Year After Adolescent Traumatic Injury

Factors Distinguishing Youth Who Report Self-Injurious Behavior: A Population-Based Sample

Development of an Algorithm for the Diagnosis of Otitis Media

Application of Classic Utilities to Published Pediatric Cost-Utility Studies

A Proposed Model Curriculum in Global Child Health for Pediatric Residents

Global Health Training in Pediatric Residency: A Qualitative Analysis of Faculty Director Insights

International Electives at the University of Minnesota Global Pediatric Residency Program: Opportunities for Education in All Accreditation Council for Graduate Medical Education Competencies

What are Residents Learning at Night? A Qualitative and Quantitative Assessment of Resident Self-Identified Learning Themes

Teaching and Evaluating Communication and Professionalism Across Pediatric Critical Care Medicine Fellowships

How Well Do Pediatric Critical Care Fellowship Programs Comply With Acgme Requirements for Teaching Professionalism and Communication?

Addressing The New Mental Health Competencies

Predicting Board Performance in Pediatrics

Creation of a Learning Goal Scoring Rubric

“Bucking the Norms”: Resident Perceptions of a Longitudinal Block Experience

Use of Wiki-Based Technology to Document Resident-Driven QI Projects

End of Life Education for Pediatric Residents During a Pediatric Intensive Care Rotation

The Effects of a Day/Night Shift System on Intern Sleep, Work Load, and Conference Attendance

Does a Neonatal Night Shift Team Increase Housestaff Exposure to Resuscitations?

The New Era of Nighttime Education: What Do Residents Want?

Identifying Gaps Between Faculty and Resident Expectations of Resident Autonomy

State of Medical Home Education in Pediatric Residency Programs

Shortening Resident Duty Hours - Does It Shortchange Student Learning?

Nighttime Resident Education Pilot: A Standardized, Web-Based Curriculum

Lack of Predictive Value of Letters of Recommendation: An Exercise in Futility

Physician Know Thy Learners: A 5-Year Description of Learning Styles Across the Generations

Learning Styles and Concept Mapping: The Chicken or The Egg

New Professionalism Challenges in Medical Training: An Exploration of Social Networking

Comparison of Institutional Coverage Models in the Era of Duty Hour Restrictions

A Prospective Randomized Trial of the Effectiveness of Lumbar Puncture Simulation Training in Pediatric Residents

E-Learning Software to Enhance Pediatric Medical Education

Teaching Residents to “Teach-Back”: Does a Structured Curriculum Including Simulation Improve Pediatric Resident Communication Skills?

Post Discharge Phone-Call Improves Asthma Care for Inner City Pediatric Patients

A Quality Improvement Initiative to Increase Nursing Attendance on Pediatric Hospitalist Family Centered Rounds

Improving Continuity Care Clinic Flow & Efficiency: A Resident Quality Improvement Project

Improving the Rate of Vitamin D Supplementation in Infants

Bundled Clinic-Based Intervention Improved 2-Dose Flu Vaccine Compliance

Accelerating CSF to Lab in Neonatal Fever Workups

Decreasing Cycle Time in a Multi-Disciplinary Clinic

Editorial Board

Contents