Preparing for Transition from Pediatric to Adult Care: Evaluation of a Physician Training Program

The Role of Internal Medicine-Pediatric Programs and Transition Champions in Graduate Medical Trainee Health Care Transition Development

OBJECTIVE

Transition to adult health care for adolescents and young adults (AYAs), especially those with chronic conditions, is a critical time. Medical trainees lack competency in providing transition care, but little is known about the factors contributing to the development of health care transition (HCT) knowledge, attitudes, and practice. This study examines how Internal Medicine-Pediatrics (Med-Peds) programs and institutional HCT champions influence trainee HCT knowledge, attitudes, and practices.

STUDY DESIGN

A 78-item electronic survey regarding the knowledge, attitudes, and practices of caring for AYA patients was sent to trainees from 11 graduate medical institutions.

RESULTS

A total of 149 responses were analyzed, including 83 from institutions with Med-Peds programs and 63 from institutions without Med-Peds programs. Trainees with an institutional Med-Peds Program were more likely to identify an institutional HCT champion (odds ratio, 10.67; 95% confidence interval, 2.40-47.44; p = .002). The mean HCT knowledge scores and use of a routine, standardized HCT tools were higher in trainees with an institutional HCT champion. Trainees without an institutional Med-Peds program experienced more barriers to HCT education. Trainees with institutional HCT champions or Med-Peds programs reported greater comfort in providing transition education and using validated, standardized transition tools.

DISCUSSION

The presence of a Med-Peds residency program was associated with a greater likelihood of a visible institutional HCT champion. Both factors were associated with increased HCT knowledge, positive attitudes, and HCT practices. Both clinical champions and adoption of Med-Peds program curricula will enhance HCT training within graduate medical education.

A Multi-Institutional Collaborative To Assess the Knowledge and Skills of Medicine-Pediatrics Residents in Health Care Transition

Background Pediatric to adult health care transition (HCT) is an essential process in the care of youth with special health care needs (YSHCN). Many internal medicine-pediatrics (med-peds) residency programs have developed curricula to teach transition knowledge and skills for the care of YSHCN. Objective Using a national med-peds program director quality improvement collaborative to improve transition curriculum, we aim to identify curricular content areas of improvement by describing baseline trainee knowledge and skills taught through existing transition curricula in med-peds programs. Methods We analyzed data collected during the 2018-2019 national med-peds program director quality improvement collaborative to improve transition curriculum. Program directors assessed their programs, and trainees assessed themselves on five transition goals by completing a Likert-scale questionnaire. In addition, trainees received an objective assessment of their knowledge through a multiple-choice questionnaire (MCQ). Results All 19 programs in the collaborative, and 193 of 316 trainees from these programs, completed the questionnaires. Most programs were based at academic centers (68%) and provided transition training via didactics (63%) and/or subspecialty rotations (58%). More programs had high confidence (95%) than trainees (58%) in goal 1 (knowledge and skills of the issues around transition), whereas more trainees had high confidence (60%) than programs (47%) in goal 2 (understanding the developmental and psychosocial aspects of transition). Programs and trainees self-assessed lower in goals related to health insurance, educational and vocational needs, and application of health care system knowledge to the practice environment (goals 3, 4, and 5, respectively). Conclusions Using the assessments of the program directors and resident trainees, we identified subject areas for improvement of transition curricula, including health insurance and the application of health care system knowledge to the practice environment.

Resident Training in Transitioning Youth With Epilepsy Into Adult Care

OBJECTIVE

To appraise the current training of Neurology (N), Pediatric (P), and Med-Peds (MP) residents at MedStar Georgetown University Hospital (MGUH) in providing care to patients with epilepsy who are transitioning from pediatric to adult care.

METHODS

Through an online questionnaire, we surveyed Neurology, Pediatric, and Med-Peds residents to assess their knowledge, confidence, and experience at transitioning youth with epilepsy to adult-oriented health care.

RESULTS

N, P, and MP residents generally rated their knowledge and confidence at providing transition care to youth with epilepsy to be poor; however, P and MP residents rated higher in limited measures of knowledge and experience.

CONCLUSION

Our appraisal of resident training in transitions care for youth with epilepsy has highlighted training elements in our institution that require attention for both adult and pediatric providers, leading to the formulation of an educational intervention that will promote experiential and multimodal approaches in this area.

Practical generic guidelines for paediatric-to-adult transition for adolescents with chronic disease

BACKGROUND

The last 20 years have seen many attempts to improve transition to adult healthcare for adolescents with chronic disease, but there is currently no established consensus on generic practices. Our goal was to identify relevant and pragmatic guidelines for transition practice for each step of this process (before, during and after transfer), applicable to a wide range of chronic illnesses and health services, via a participatory approach involving all the key stakeholders.

METHODS

We conducted interviews and a literature review to elaborate a questionnaire for use in an online 2-round Delphi survey. The survey panel included 36 French health and social professionals from different care settings, and young adults and parents with an experience of healthcare transition related to all types of chronic disease.

RESULTS

The survey consensus identified 19 items on feasibility and relevance criteria, which form the guidelines. It is composed of five practices to be adopted during preparation in paediatrics, seven practices in the active phase of transition and seven in adult care. Two guidelines achieved complete consensus: having a longer consultation for the first appointment with the adult doctor, and keeping the same adult doctor throughout follow-up. A further 36 items met the criterion of relevance, but were deemed unfeasible.

CONCLUSIONS

Taking into account all stakeholder views and the real-world applicability of care practices enabled us to elaborate consensual guidelines whose implementation requires no additional health service resources.

Lost in transition: resident and fellow training and experience caring for young adults with chronic conditions in a large United States' academic medical center

BACKGROUND

The transition from pediatric to adult healthcare is a vulnerable time for adolescents and young adults (AYA), especially those with chronic conditions. Successful transition requires communication and coordination amongst providers, patients, and families. Unfortunately, multiple studies have demonstrated that the majority of practicing providers do not feel prepared to help AYA patients through health care transition, but little is known about the transition/transfer aptitudes of physician trainees.

OBJECTIVES

The purpose of this study was to establish the transition/transfer training that residents and fellows from different fields receive - and determine what training factors are associated with increased confidence in core transition/transfer skills.

DESIGN

A 20-item electronic survey regarding experiences caring for AYA patients was sent to all 2014-2015 graduate medical education (GME) trainees at our institution.

RESULTS

Forty-nine percent (479/985) of trainees responded: 60 pediatric, 387 non-pediatric, and 32 'combined' (e.g., Medicine/Pediatrics or Family Medicine). Trainees from all three categories of programs reported similar exposure to AYA patients with chronic conditions, with a median of 1-3 encounters per month. A quarter of trainees rated themselves as 'not at all prepared' to speak with a counterpart provider about a transferring patient, while nearly half of trainees considered themselves 'not at all prepared' to speak with a patient and family about transition. Trainee confidence in performing these two skills was strongly predicted by three factors: increased exposure to AYA with chronic conditions, education (training or role modeling) in transition skills, and experience practicing transition skills. Of these, the strongest association with trainee confidence was experience practicing the skills of communicating with other providers (OR = 13.0) or with patients/families (OR = 14.5).

CONCLUSION

Despite at least monthly encounters with AYA with chronic conditions, most residents and fellows have very little experience communicating across the pediatric-to-adult healthcare divide, highlighting training opportunities in graduate medical education.