Efficacy of Empiric Treatment of Urinary Tract Infections in Neonates and Young Infants

Background. The antibiotic resistance patterns of young infants with urinary tract infections (UTIs) have evolved over the past 2 decades. Whether current empiric antibiotic regimens are sufficient in this age group is unknown. Methods. A retrospective review of patients aged 0 to 60 days admitted with a UTI discharge diagnosis. Results. Overall susceptibility to empiric antibiotics was 87%. Antibiotic resistance and length of stay were highest among those who were afebrile, those admitted to the intensive care unit, and those with culture diagnosis of enterococcal infection. The sensitivity and specificity of ultrasound as a screening tool for genitourinary anomaly was 70% and 40%, respectively, with a positive predictive value of 31.8%. Conclusions. Empiric antibiotic regimens cover a high percentage of UTIs in infants. However, high rates of resistance and prolonged length of stay in patients with enterococcal infection highlight the need for continued surveillance of such patients in this age group.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients’ perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10–50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07–2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers’ likelihood of exploring context but not contextualizing care. Information about patients’ life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Do Mindfulness and Self-Compassion Predict Burnout in Pediatric Residents?

PURPOSE

Burnout symptoms are common among health professionals. Gaps remain in understanding both the stability of burnout and compassion over time and relationships among burnout, self-compassion, stress, and mindfulness in pediatric residents.

METHOD

The authors conducted a prospective cohort study of residents at 31 U.S. residency programs affiliated with the Pediatric Resident Burnout-Resilience Study Consortium. Residents completed online cross-sectional surveys in spring 2016 and 2017. The authors assessed demographic characteristics and standardized measures of mindfulness, self-compassion, stress, burnout, and confidence in providing compassionate care.

RESULTS

Of 1,108 eligible residents, 872 (79%) completed both surveys. Of these, 72% were women. The prevalence of burnout was 58% and the level of mindfulness was 2.8 in both years; levels of stress (16.4 and 16.2) and self-compassion (37.2 and 37.6) were also nearly identical in both years. After controlling for baseline burnout levels in linear mixed-model regression analyses, mindfulness in 2016 was protective for levels of stress and confidence in providing compassionate care in 2017. Self-compassion in 2016 was protective for burnout, stress, and confidence in providing compassionate care in 2017; a one-standard-deviation increase in self-compassion score was associated with a decrease in the probability of burnout from 58% to 48%.

CONCLUSIONS

Burnout and stress were prevalent and stable over at least 12 months among pediatric residents. Mindfulness and self-compassion were longitudinally associated with lower stress and greater confidence in providing compassionate care. Future studies are needed to evaluate the effectiveness of training that promotes mindfulness and self-compassion in pediatric residents.

Burnout in Pediatric Residents: Comparing Brief Screening Questions to the Maslach Burnout Inventory

BACKGROUND

Measuring burnout symptoms is important, but the Maslach Burnout Inventory (MBI) has 22 items. This project compared 3 single-item measures with the MBI and other factors related to burnout.

METHODS

Data were analyzed from the 2016 and 2017 Pediatric Resident Burnout-Resilience Study Consortium surveys, which included standard measures of perceived stress, mindfulness, resilience, and self-compassion; the MBI; and the 1- and 2-item screening questions.

RESULTS

In 2016 and 2017, data were collected from 1785/2723 (65%) and 2148/3273 (66%) eligible pediatric residents, respectively. Burnout rates on the MBI were 56% in 2016 and 54% in 2017. The Physician Work Life Study item generated estimates of burnout prevalence of 43% to 49% and, compared with the MBI for 2016 and 2017, had sensitivities of 69% to 72%, specificities of 79% to 82%, positive likelihood ratios of 3.4 to 3.8, and negative likelihood ratios of 0.35 to 0.38. The combination of an emotional exhaustion item and a depersonalization item generated burnout estimates of 53% in both years and, compared with the full MBI, had sensitivities of 85% to 87%, specificities of 84% to 85%, positive likelihood ratios of 5.7 to 6.4, and negative likelihood ratios of 0.18 for both years. Both items were significantly correlated with their parent subscales. The single items were significantly correlated with stress, mindfulness, resilience, and self-compassion.

CONCLUSIONS

The 1- and 2-item screens generated prevalence estimates similar to the MBI and were correlated with variables associated with burnout. The 1- and 2-item screens may be useful for pediatric residency training programs tracking burnout symptoms and response to interventions.

Variability of Burnout and Stress Measures in Pediatric Residents: An Exploratory Single-Center Study From the Pediatric Resident Burnout-Resilience Study Consortium

Residency is a high-risk period for physician burnout. We aimed to determine the short-term stability of factors associated with burnout, application of these data to previous conceptual models, and the relationship of these factors over 3 months. Physician wellness questionnaire results were analyzed at 2 time points 3 months apart. Associations among variables within and across time points were analyzed. Logistic regression was used to predict burnout and compassionate care. A total of 74% of residents completed surveys. Over 3 months, burnout ( P = .005) and empathy ( P = .04) worsened. The most significant cross-sectional relationship was between stress and emotional exhaustion (time 1 r = 0.61, time 2 r = 0.68). Resilience was predictive of increased compassionate care and decreased burnout ( P < .05). Mindfulness was predictive of decreased burnout ( P < .05). Mitigating stress and fostering mindfulness and resilience longitudinally may be key areas of focus for improved wellness in pediatric residents. Larger studies are needed to better develop targeted wellness interventions.

Crossing the Gap: Using Competency-Based Assessment to Determine Whether Learners Are Ready for the Undergraduate-to-Graduate Transition

In 2011, the Education in Pediatrics Across the Continuum (EPAC) Study Group recruited four medical schools (University of California, San Francisco; University of Colorado; University of Minnesota; and University of Utah) and their associated pediatrics clerkship and residency program directors to be part of a consortium to pilot a model designed to advance learners from undergraduate medical education (UME) to graduate medical education (GME) and then to fellowship or practice based on competence rather than time spent in training. The central design features of this pilot included predetermined expectations of performance and transition criteria to ensure readiness to progress from UME to GME, using the Core Entrustable Professional Activities for Entering Residency (Core EPAs) as a common assessment framework. Using this framework, each site team (which included, but was not limited to, the EPAC course, pediatric clerkship, and pediatric residency program directors) monitored learners' progress, with the site's clinical competency committee marking the point of readiness to transition from UME to GME (i.e., the attainment of supervision level 3a). Two of the sites implemented time-variable transition from UME to GME, based on when a learner met the performance expectations and transition criteria. In this Article, the authors describe each of the four sites' implementation of Core EPA assessment and their approach to gathering the data necessary to determine readiness for transition. They conclude by offering recommendations and lessons learned from the pilot's first seven years of development, adaptation, and implementation of assessment strategies across the sites, and discussing next steps.

An Exploratory Pilot Study to Describe Shared Decision-Making for PTSD Treatment Planning: The Provider Perspective

OBJECTIVE

To describe current practices used by Veterans Administration (VA) mental health (MH) providers involved in post-traumatic stress disorder (PTSD) treatment planning to support engagement of veterans with PTSD in shared decision-making (SDM).

METHODS

Semi-structured interviews with MH providers (n = 9) were conducted at 1 large VA, audio-recorded, and transcribed verbatim. Transcripts were analyzed deductively, guided by a published account of the integral SDM components for MH care.

RESULTS

While discussing forming a cohesive team with patients, providers noted the importance of establishing rapport and assessing treatment readiness. Providers' clinical knowledge/expertise, knowledge of the facility's treatment options, knowledge of how to navigate the VA MH care system, and patient factors (goals/preferences, factors influencing treatment engagement) were noted as important to consider when patients and providers exchange information. When negotiating the treatment plan, providers indicated that conversations should include treatment recommendations and concurrent opportunities for personalization. They also emphasized the importance of discussions to finalize a mutually agreeable patient- and provider-informed treatment plan and measure treatment impact.

CONCLUSION

These results offer a preliminary understanding of VA MH providers' facilitation of SDM for PTSD care. Findings may provide insights for MH providers who wish to engage patients with PTSD in SDM.

Milestone Ratings and Supervisory Role Categorizations Swim Together, but Is the Water Muddy?

OBJECTIVE

This single-specialty, multi-institutional study aimed to determine 1) the association between milestone ratings for individual competencies and average milestone ratings (AMRs) and 2) the association between AMRs and recommended supervisory role categorizations made by individual clinical competency committee (CCC) members.

METHODS

During the 2015-16 academic year, CCC members at 14 pediatric residencies reported milestone ratings for 21 competencies and recommended supervisory role categories (may not supervise, may supervise in some settings, may supervise in all settings) for residents they reviewed. An exploratory factor analysis of competencies was conducted. The associations among individual competencies, the AMR, and supervisory role categorizations were determined by computing bivariate correlations. The relationship between AMRs and recommended supervisory role categorizations was examined using an ordinal mixed logistic regression model.

RESULTS

Of the 155 CCC members, 68 completed both milestone assignments and supervision categorizations for 451 residents. Factor analysis of individual competencies controlling for clustering of residents in raters and sites resulted in a single-factor solution (cumulative variance: 0.75). All individual competencies had large positive correlations with the AMR (correlation coefficient: 0.84-0.93), except for two professionalism competencies (Prof1: 0.63 and Prof4: 0.65). When combined across training year and time points, the AMR and supervisory role categorization had a moderately positive correlation (0.56).

CONCLUSIONS

This exploratory study identified a modest correlation between average milestone ratings and supervisory role categorization. Convergence of competencies on a single factor deserves further exploration, with possible rater effects warranting attention.

Key Factors in Clinical Competency Committee Members' Decisions Regarding Residents' Readiness to Serve as Supervisors: A National Study

PURPOSE

Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role.

METHOD

CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis.

RESULTS

Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015-2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play.

CONCLUSIONS

CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.

Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study

OBJECTIVES

To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting.

STUDY DESIGN

We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ² tests, and Poisson regression.

RESULTS

Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening.

CONCLUSIONS

Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

A novel workplace-based assessment for competency-based decisions and learner feedback

BACKGROUND

Increased recognition of the importance of competency-based education and assessment has led to the need for practical and reliable methods to assess relevant skills in the workplace.

METHODS

A novel milestone-based workplace assessment system was implemented in 15 pediatrics residency programs. The system provided: (1) web-based multisource feedback (MSF) and structured clinical observation (SCO) instruments that could be completed on any computer or mobile device; and (2) monthly feedback reports that included competency-level scores and recommendations for improvement.

RESULTS

For the final instruments, an average of five MSF and 3.7 SCO assessment instruments were completed for each of 292 interns; instruments required an average of 4-8 min to complete. Generalizability coefficients >0.80 were attainable with six MSF observations. Users indicated that the new system added value to their existing assessment program; the need to complete the local assessments in addition to the new assessments was identified as a burden of the overall process.

CONCLUSIONS

Outcomes - including high participation rates and high reliability compared to what has traditionally been found with workplace-based assessment - provide evidence for the validity of scores resulting from this novel competency-based assessment system. The development of this assessment model is generalizable to other specialties.

Does Incorporating a Measure of Clinical Workload Improve Workplace-Based Assessment Scores? Insights for Measurement Precision and Longitudinal Score Growth From Ten Pediatrics Residency Programs

PURPOSE

This study investigates the impact of incorporating observer-reported workload into workplace-based assessment (WBA) scores on (1) psychometric characteristics of WBA scores and (2) measuring changes in performance over time using workload-unadjusted versus workload-adjusted scores.

METHOD

Structured clinical observations and multisource feedback instruments were used to collect WBA data from first-year pediatrics residents at 10 residency programs between July 2016 and June 2017. Observers completed items in 8 subcompetencies associated with Pediatrics Milestones. Faculty and resident observers assessed workload using a sliding scale ranging from low to high; all item scores were rescaled to a 1-5 scale to facilitate analysis and interpretation. Workload-adjusted WBA scores were calculated at the item level using three different approaches, and aggregated for analysis at the competency level. Mixed-effects regression models were used to estimate variance components. Longitudinal growth curve analyses examined patterns of developmental score change over time.

RESULTS

On average, participating residents (n = 252) were assessed 5.32 times (standard deviation = 3.79) by different raters during the data collection period. Adjusting for workload yielded better discrimination of learner performance, and higher reliability, reducing measurement error by 28%. Projections in reliability indicated needing up to twice the number of raters when workload-unadjusted scores were used. Longitudinal analysis showed an increase in scores over time, with significant interaction between workload and time; workload also increased significantly over time.

CONCLUSIONS

Incorporating a measure of observer-reported workload could improve the measurement properties and the ability to interpret WBA scores.

Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice

BACKGROUND

The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown.

OBJECTIVE

To determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate.

METHODS

Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis.

RESULTS

The response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21-2.71) and professionalization (2.37; 95% CI, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions.

CONCLUSIONS

Most PDs have not established program minimum Milestones, but would vary such expectations according to competency.

Resident hesitation in the operating room: does uncertainty equal incompetence?

CONTEXT

In postgraduate medical programmes, the progressive development of autonomy places residents in situations in which they must cope with uncertainty. We explored the phenomenon of hesitation, triggered by uncertainty, in the context of the operating room in order to understand the social behaviours surrounding supervision and progressive autonomy.

METHODS

Nine surgical residents and their supervising surgeons at a Canadian medical school were selected. Each resident-supervisor pair was observed during a surgical procedure and subsequently participated in separate post-observation, semi-structured interviews. Constructivist grounded theory was used to guide the collection and analysis of data.

RESULTS

Three hesitation-related themes were identified: the principle of progress; the meaning of hesitation, and the judgement of competence. Supervisors and residents understood hesitation in the context of a core surgical principle we termed the 'principle of progress'. This principle reflects the supervisors' and residents' shared norm that maintaining progress throughout a surgical procedure is of utmost importance. Resident hesitation was perceived as the first indication of a disruption to this principle and was therefore interpreted by supervisors and residents alike as a sign of incompetence. This interpretation influenced the teaching-learning process during these moments when residents were working at the edge of their abilities.

CONCLUSIONS

The principle of progress influences the meaning of hesitation which, in turn, shapes judgements of competence. This has important implications for teaching and learning in direct supervision settings such as surgery. Without efforts to change the perception that hesitation represents incompetence, these potential teaching-learning moments will not fully support progressive autonomy.

Development, administration, and validity evidence of a subspecialty preparatory test toward licensure: a pilot study

BACKGROUND

Trainees in medical subspecialties lack validated assessment scores that can be used to prepare for their licensing examination. This paper presents the development, administration, and validity evidence of a constructed-response preparatory test (CRPT) administered to meet the needs of nephrology trainees.

METHODS

Learning objectives from the licensing examination were used to develop a test blueprint for the preparatory test. Messick's unified validity framework was used to gather validity evidence for content, response process, internal structure, relations to other variables, and consequences. Questionnaires were used to gather data on the trainees' perception of examination preparedness, item clarity, and curriculum adequacy.

RESULTS

There were 10 trainees and 5 faculty volunteers who took the test. The majority of trainees passed the constructed-response preparatory test. However, many scored poorly on items assessing renal pathology and physiology knowledge. We gathered the following five sources of validity evidence: (1) Content: CRPT mapped to the licensing examination blueprint, with items demonstrating clarity and range of difficulty; (2) Response process: moderate rater agreement (intraclass correlation = .58); (3) Internal structure: sufficient reliability based on generalizability theory (G-coefficient = .76 and Φ-coefficient = .53); (4) Relations to other variables: CRPT scores reflected years of exposure in nephrology and clinical practice; (5) Consequences: post-assessment survey revealed that none of the test takers felt "poorly prepared" for the upcoming summative examination and that their studying would increase in duration and be adapted in terms of content focus.

CONCLUSIONS

Preparatory tests using constructed response items mapped to licensure examination blueprint can be developed and used at local program settings to help prepare learners for subspecialty licensure examinations. The CRPT and questionnaire data identified shortcomings of the nephrology training program curriculum. Following the preparatory test, trainees expressed an improved sense of preparedness for their licensing examination.

Reductions in dead space ventilation with nasal high flow depend on physiological dead space volume: metabolic hood measurements during sleep in patients with COPD and controls

Nasal high flow (NHF) reduces minute ventilation and ventilatory loads during sleep but the mechanisms are not clear. We hypothesised NHF reduces ventilation in proportion to physiological but not anatomical dead space.11 subjects (five controls and six chronic obstructive pulmonary disease (COPD) patients) underwent polysomnography with transcutaneous carbon dioxide (CO₂) monitoring under a metabolic hood. During stable non-rapid eye movement stage 2 sleep, subjects received NHF (20 L·min^-1) intermittently for periods of 5-10 min. We measured CO₂ production and calculated dead space ventilation.Controls and COPD patients responded similarly to NHF. NHF reduced minute ventilation (from 5.6±0.4 to 4.8±0.4 L·min^-1; p<0.05) and tidal volume (from 0.34±0.03 to 0.3±0.03 L; p<0.05) without a change in energy expenditure, transcutaneous CO₂ or alveolar ventilation. There was a significant decrease in dead space ventilation (from 2.5±0.4 to 1.6±0.4 L·min^-1; p<0.05), but not in respiratory rate. The reduction in dead space ventilation correlated with baseline physiological dead space fraction (r²=0.36; p<0.05), but not with respiratory rate or anatomical dead space volume.During sleep, NHF decreases minute ventilation due to an overall reduction in dead space ventilation in proportion to the extent of baseline physiological dead space fraction.

Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments

PURPOSE

Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments.

METHOD

From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents.

RESULTS

The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories.

CONCLUSIONS

The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.

Incidence, outcomes, and resource use in children with Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND/OBJECTIVES

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening cutaneous reactions, typically to drugs or infection. The incidence and outcomes of these conditions in children are unknown. The objective of this study was to report the overall burden of Stevens-Johnson syndrome and toxic epidermal necrolysis in children in the United States.

METHODS

We performed a retrospective cohort analysis of children and adolescents younger than 18 years of age using the 2009 and 2012 Kids' Inpatient Database.

RESULTS

We identified 1486 children and adolescents hospitalized with a diagnosis of Stevens-Johnson syndrome or toxic epidermal necrolysis. The national incidence per 100 000 was 6.3 for Stevens-Johnson syndrome, 0.7 for Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome, and 0.5 for toxic epidermal necrolysis. The highest incidence in children was in those aged 11-15 years (38.4 per 100 000). Toxic epidermal necrolysis and Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome were associated with longer stay, greater mortality, and higher hospital charges than those with Stevens-Johnson syndrome. Hospital mortality was highest in children with toxic epidermal necrolysis and in children aged 0-5 years.

CONCLUSIONS

The incidence of Stevens-Johnson syndrome and toxic epidermal necrolysis in children is higher than reported in adults, and there are significant age-based variations in incidence and outcomes across the pediatric population. Further study is needed to determine the most effective treatment strategies to reduce costs and improve outcomes in children hospitalized with severe cutaneous reactions.

Functional MR Mapping of Activated Cortical Areas

Magnetic resonance imaging (MRI) has recently been demonstrated to be sensitive to changes in neuronal activity of cortical areas. We report our initial experiences with functional MR brain mapping at high spatial resolution using a conventional whole-body MR system. A total of 10 visual and motor cortex activation studies were carried out on 8 healthy volunteers. In each examination, a time course series of 15 strongly T2*-weighted FLASH images was measured from three adjacent slices. The image analysis revealed a subtle but highly significant signal increase in cortical layers of gray matter in primary and associative visual as well as sensorimotoric cortex regions during periods of excessive brain activity provoked by photic stimuli or motoric tasks, respectively. To correlate brain structure and brain function, the computed MR brain activation maps were directly superimposed on T1-weighted anatomic spin-echo images. With this advance into the area of functional neuroimaging, MRI is moving into an established domain of positron emission tomography (PET). We, therefore, discuss the advantages and limitations of the MR method in comparison to PET as far as this can be done at present.

Validity of Level of Supervision Scales for Assessing Pediatric Fellows on the Common Pediatric Subspecialty Entrustable Professional Activities

PURPOSE

Entrustable professional activities (EPAs) represent the routine and essential activities that physicians perform in practice. Although some level of supervision scales have been proposed, they have not been validated. In this study, the investigators created level of supervision scales for EPAs common to the pediatric subspecialties and then examined their validity in a study conducted by the Subspecialty Pediatrics Investigator Network (SPIN).

METHOD

SPIN Steering Committee members used a modified Delphi process to develop unique scales for six of the seven common EPAs. The investigators sought validity evidence in a multisubspecialty study in which pediatric fellowship program directors and Clinical Competency Committees used the scales to evaluate fellows in fall 2014 and spring 2015.

RESULTS

Separate scales for the six EPAs, each with five levels of progressive entrustment, were created. In both fall and spring, more than 300 fellows in each year of training from over 200 programs were assessed. In both periods and for each EPA, there was a progressive increase in entrustment levels, with second-year fellows rated higher than first-year fellows (P < .001) and third-year fellows rated higher than second-year fellows (P < .001). For each EPA, spring ratings were higher (P < .001) than those in the fall. Interrater reliability was high (Janson and Olsson's iota = 0.73).

CONCLUSIONS

The supervision scales developed for these six common pediatric subspecialty EPAs demonstrated strong validity evidence for use in EPA-based assessment of pediatric fellows. They may also inform the development of scales in other specialties.

Medical judgement analogue studies with applications to spaceflight crew medical officer

Background

The National Aeronautics and Space Administration (NASA) developed plans for potential emergency conditions from the Exploration Medical Conditions List. In an effort to mitigate conditions on the Exploration Medical Conditions List, NASA implemented a crew medical officer (CMO) designation for eligible astronauts. This pilot study aims to add knowledge that could be used in the Integrated Medical Model.

Methods

An analogue population was recruited for two categories: administrative physicians (AP) representing the physician CMOs and technical professionals (TP) representing the non-physician CMOs. Participants completed four medical simulations focused on abdominal pain: cholecystitis (CH) and renal colic (RC) and chest pain: cardiac ischaemia (STEMI; ST-segment elevation myocardial infarction) and pneumothorax (PX). The Medical Judgment Metric (MJM) was used to evaluate medical decision making.

Results

There were no significant differences between the AP and TP groups in age, gender, race, ethnicity, education and baseline heart rate. Significant differences were noted in MJM average rater scores in AP versus TP in CH: 13.0 (±2.25), 4.5 (±0.48), p=<0.001; RC: 12.3 (±2.66), 4.8 (±0.94); STEMI: 12.1 (±3.33), 4.9 (±0.56); and PX: 13.5 (±2.53), 5.3 (±1.01), respectively.

Discussion

There could be a positive effect on crew health risk by having a physician CMO. The MJM demonstrated the ability to quantify medical judgement between the two analogue groups of spaceflight CMOs. Future studies should incorporate the MJM in a larger analogue population study to assess the medical risk for spaceflight crewmembers.

Acute Kidney Injury Impairs Postnatal Renal Adaptation and Increases Morbidity and Mortality in Very Low-Birth-Weight Infants

OBJECTIVE

This study aims to estimate the impact of acute kidney injury (AKI) on postnatal renal adaptation, morbidity, and mortality in very low-birth-weight (VLBW) infants.

DESIGN

We conducted a retrospective study of 457 VLBW infants admitted to a tertiary level neonatal intensive care unit (NICU) between July 2009 and April 2015. We compared patient characteristics, risk factors, serum creatinine trends, and adverse outcomes in infants with and without AKI using multivariate logistic regression analysis.

RESULTS

Incidence of AKI was 19.5%. On multivariate analysis, postnatal risk factors such as patent ductus arteriosus and vancomycin use were significantly associated with AKI. Infants with AKI had significantly higher mortality; 25/89 (28%) versus 15/368 (4%) (p < 0.001). Among survivors with AKI, bronchopulmonary dysplasia (BPD) was more prevalent (52.8 vs. 23.9%, p < 0.001), serum creatinine remained elevated for a longer duration and median length of stay extended by 38 days.

CONCLUSION

Presence of AKI was associated with impaired postnatal renal adaptation, BPD, significantly longer stay in the NICU and higher mortality.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns

BACKGROUND

Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention.

METHODS

Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis.

RESULTS

Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed.

CONCLUSIONS

Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Failure to flow: An exploration of learning and teaching in busy, multi-patient environments using an interpretive description method

INTRODUCTION

As patient volumes continue to increase, more attention must be paid to skills that foster efficiency without sacrificing patient safety. The emergency department is a fertile ground for examining leadership and management skills, especially those that concern prioritization in multi-patient environments. We sought to understand the needs of emergency physicians (EPs) and emergency medicine junior trainees with regards to teaching and learning about how best to handle busy, multi-patient environments.

METHOD

A cognitive task analysis was undertaken, using a qualitative approach to elicit knowledge of EPs and residents about handling busy emergency department situations. Ten experienced EPs and 10 junior emergency medicine residents were interviewed about their experiences in busy emergency departments. Transcripts of the interviews were analyzed inductively and iteratively by two independent coders using an interpretive description technique.

RESULTS

EP teachers and junior residents differed in their perceptions of what makes an emergency department busy. Moreover, they focused on different aspects of patient care that contributed to their busyness: EP teachers tended to focus on volume of patients, junior residents tended to focus on the complexity of certain cases. The most important barrier to effective teaching and learning of managerial skills was thought to be the lack of faculty development in this skill set.

CONCLUSIONS

This study presents qualitative data that helps us elucidate how patient volumes affect our learning environments, and how clinical teachers and residents operate within these environments.

A Behavioral Economic Approach to Improving Human Papillomavirus Vaccination

PURPOSE

The objectives of this study were to measure the impact of a behavioral economic intervention on human papillomavirus (HPV) vaccine initiation and series completion rates for adolescents and to measure the impact of the intervention on the receipt of a nonincentivized influenza vaccine.

METHODS

We conducted a quasi-randomized trial to compare the impact of an escalating delayed cash incentive (intervention), compared with usual care (control), on HPV vaccination initiation and series completion rates among adolescents (11-17 years) at an urban medical center. We measured HPV vaccine initiation and completion rates during the 12 months after enrollment and subsequent influenza vaccination rates for 24 months after enrollment.

RESULTS

A total of 85 participants were actively enrolled in the intervention arm and 103 were passively enrolled in the control arm. Participants were predominantly publically insured African-American and Hispanic adolescents. The majority (75%) of the intervention group received one or more doses of the HPV vaccine, with 36% completing the three-dose series, compared with 47% of the control group receiving one or more doses and only 13% completing the series. The odds of HPV p-value vaccine initiation (odds ratio 4.19 [95% confidence interval 1.84-10.10], p < .01) and HPV vaccine series completion (OR 4.16 [95% confidence interval 1.64-11.28], p < .01) were greater among the intervention group compared with the control group. There was no difference in influenza vaccination rates between the intervention group and the control group during the 2013-2014 season (p = .138) and during the 2014-2015 influenza season (p value .683).

CONCLUSIONS

An incentive-based approach to HPV vaccination was effective in increasing vaccine initiation and series dose completion.

Integrating Education and Service in Pediatric Residency Training: Results of a National Survey

OBJECTIVE

The definition and proper role of service, as it relates to education, in the residency training experience has been long debated. In this study we aimed to develop definitions for service and education, delineate how each is perceived to contribute value to training, and to measure respondents' ratings of service and education using case vignettes.

METHODS

We conducted a multisite cohort survey study of pediatric residents (n = 797) and program directors (PDs; n = 37) using a region-stratified sample of 2 to 3 participating pediatric residency programs per region.

RESULTS

Surveys were completed by 34 PDs (92%) and 359 trainees (45%). PDs and residents agree that service can, in the absence of formal teaching, be considered educational. When asked how often rotations provide an appropriate balance between education and service, 94% of PDs responded 'extremely/very often' whereas only 68% of residents agreed (P = .005). Residents were significantly more likely than PDs to endorse definitions for service that included volunteer work (82% vs 59%; P = .002), going above and beyond for a patient (91% vs 78%; P = .017), and routine patient care activities (91% vs 72%; P < .001). For 6 of 12 case vignettes, trainees gave median service ratings that were significantly higher than PDs (P = .03).

CONCLUSIONS

Medical educators and pediatric residents hold mismatched impressions of their training programs' balance of service obligations with clinical education. Specifically, residents more frequently report an overabundance of service. Both groups acknowledge that service activities can be educationally valuable although the groups' definitions of service are not fully aligned.

Medical student, nursing student, and non-health care respondents' implicit attitudes toward doctors and patients: Development and a pilot study of a new implicit attitudes test (IAT)

Introduction

Medical educators have been concerned that medical students may decline in empathy for patients during the course of their training, based on studies measuring clinical empathy using psychometrically strong self-report measures. Clinical empathy is a complex construct, incorporating attitudes toward patients but also other components, such as professional detachment. Triangulation of extant measures with instruments based on nonreactive methods could provide a better understanding of whether and how physician attitudes toward patients may be changing during training. We sought to develop and pilot-test such a nonreactive method.

Methods

We develop variations of an implicit association test (IAT) designed to measure attitudes toward physicians and patients based on speed of reaction to images of actors and positive and negative words. In the IATs, the same actors are photographed as doctors, clinic outpatients, hospitalized inpatients, and as a “general public” control. We examine preliminary evidence for their validity by collecting pilot data from internet participants (not involved in the health professions), medical students, and nursing students.

Results

Internet participants (n = 314) and nursing students (n = 31) had more negative associations (IAT scores) with doctors than did medical students (n = 89); nursing students and female internet participants had more positive associations with hospitalized patients than did medical students and male internet participants. Medical students’ associations with hospitalized patients varied by year of training.

Discussion

This IAT may provide insight into implicit attitudes among those who enter training for the health profession and changes in those attitudes that may be inculcated during that training.

Development, Validation, and Implementation of a Medical Judgment Metric

Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss’s Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen’s Kappa 0.851 to 0.880). Discussion: The MJM demonstrated preliminary evidence of reliability and validity.

Validity Evidence From Ratings of Pediatric Interns and Subinterns on a Subset of Pediatric Milestones

PURPOSE

To investigate evidence for validity of faculty members' pediatric milestone (PM) ratings of interns (first-year residents) and subinterns (fourth-year medical students) on nine subcompetencies related to readiness to serve as a pediatric intern in the inpatient setting.

METHOD

The Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN) and the National Board of Medical Examiners collaborated to investigate the utility of assessments of the PMs for trainees' performance. Data from 32 subinterns and 179 interns at 17 programs were collected from July 2012 through April 2013. Observers used several tools to assess learners. At each site, a faculty member used these data to make judgments about the learner's current developmental milestone in each subcompetency. Linear mixed models were fitted to milestone judgments to examine their relationship with learner's rank and subcompetency.

RESULTS

On a 5-point developmental scale, mean milestone levels for interns ranged from 3.20 (for the subcompetency Work effectively as a member of a team) to 3.72 (Humanism) and for subinterns from 2.89 (Organize and prioritize care) to 3.61 (Professionalization). Mean milestone ratings were significantly higher for the Professionalism competency (3.59-3.72) for all trainees compared with Patient Care (2.89-3.24) and Personal and Professional Development (3.33-3.51). Mean intern ratings were significantly higher than mean subintern ratings for all nine subcompetencies except Professionalization, Humanism, and Trustworthiness.

CONCLUSIONS

The PMs had a coherent internal structure and could distinguish between differing levels of trainees, which supports their validation for documenting developmental progression of pediatric trainees.