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McBain RK, Levin JS, Matthews S, Qureshi N, Long D, Schickedanz AB, Gilgoff R, Kotz K, Slavich GM, Eberhart NK. The effect of adverse childhood experience training, screening, and response in primary care: a systematic review. EClinicalMedicine 2023; 65:102282. [PMID: 38106557 PMCID: PMC10725064 DOI: 10.1016/j.eclinm.2023.102282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
Background Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care. Methods This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports. Findings Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction. Interpretation Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce. Funding The California Department of Health Care Services and the Office of the California Surgeon General.
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Affiliation(s)
- Ryan K. McBain
- Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
- Division of Healthcare Delivery, RAND Corporation, Washington, DC, USA
| | - Jonathan S. Levin
- Division of Healthcare Delivery, RAND Corporation, Washington, DC, USA
| | - Samantha Matthews
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
| | - Nabeel Qureshi
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
| | - Dayna Long
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Adam B. Schickedanz
- Department of Pediatrics, David Geffen School of Medicine and Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Rachel Gilgoff
- UCLA-UCSF ACEs Aware Family Resilience Network, Los Angeles, CA, USA
| | - Krista Kotz
- UCLA-UCSF ACEs Aware Family Resilience Network, Los Angeles, CA, USA
| | - George M. Slavich
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Nicole K. Eberhart
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
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Woodman J, Simon A, Hauari H, Gilbert R. A scoping review of 'think-family' approaches in healthcare settings. J Public Health (Oxf) 2021; 42:21-37. [PMID: 30668870 DOI: 10.1093/pubmed/fdy210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 09/27/2018] [Accepted: 11/06/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND 'Think-family' child health approaches treat child and parent/carer health as inter-related. They are promoted within health policy internationally (also called 'family paediatrics' or 'whole-family', 'family-centred' approaches or 'child-centred' approaches within adult services). METHODS We reviewed publications of think-family interventions. We developed a typology of these interventions using thematic analysis of data extracted from the included studies. RESULTS We included 62 studies (60% USA and 18% UK); 45/62 (73%) treated the parent as patient, helping the child by addressing parental mental health, substance and alcohol misuse and/or domestic violence. Our typology details three common mechanisms of change in relevant interventions: screening, health promotion and developing relationships (inter-professional and parent-professional). CONCLUSIONS Policy-makers, practitioners and researchers can use our typology to develop and evaluate think-family approaches within healthcare. Strong relationships between parents and professionals are key in think-family approaches and should be considered in service design. Although helping the child through the parent may be a good place to start for service development, care is needed to ensure parental need does not eclipse child need. Strategies that reach out to the parent behind the child (child as patient) and which work simultaneously with parent and child warrant attention.
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Affiliation(s)
- Jenny Woodman
- UCL-Institute of Education, Thomas Coram Research Unit, 27/8 Woburn Square, London, UK
| | - Antonia Simon
- UCL-Institute of Education, Social Science Research Unit, 27/8 Woburn Square, London, UK
| | - Hanan Hauari
- UCL-Institute of Education, Thomas Coram Research Unit, 27/8 Woburn Square, London, UK
| | - Ruth Gilbert
- UCL-GOS- Institute of Child Health, 30 Guilford Street, London, UK
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Hill SG, Phan TLT, Datto GA, Hossain J, Werk LN, Abatemarco D. Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States. J Child Health Care 2019; 23:63-78. [PMID: 29792063 PMCID: PMC6105559 DOI: 10.1177/1367493518777308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.
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Affiliation(s)
- Samareh G Hill
- Department of Pediatric Weight Management, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Thao-Ly T Phan
- Division of Weight Management, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - George A Datto
- Division of Weight Management, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Jobayer Hossain
- Department of Biomedical Research, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Lloyd N Werk
- Division of General Academic Pediatrics, Nemours Children’s Hospital, Orlando, FL, USA
| | - Diane Abatemarco
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
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Chung EK, Gubernick RS, LaNoue M, Abatemarco DJ. Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary Care Setting. Acad Pediatr 2019; 19:227-235. [PMID: 30273689 DOI: 10.1016/j.acap.2018.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving low-income children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision. METHODS A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves-pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)-to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training. RESULTS A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation. CONCLUSIONS Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.
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Affiliation(s)
- Esther K Chung
- Department of Pediatrics (EK Chung),; Nemours/Alfred I. duPont Hospital for Children (EK Chung), Wilmington, Del.
| | | | | | - Diane J Abatemarco
- Department of Obstetrics and Gynecology (D Abatemarco), Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Penn
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Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0-3 years. Prim Health Care Res Dev 2017; 19:365-377. [PMID: 29248033 DOI: 10.1017/s1463423617000810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Child maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents. OBJECTIVE This paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011. METHODS A within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices' processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months. RESULTS Quantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes. CONCLUSION Lessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0-3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.
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Di Guglielmo MD, Greenspan JS, Abatemarco DJ. Pediatrician preferences, local resources, and economic factors influence referral to a subspecialty access clinic. Prim Health Care Res Dev 2016; 17:628-635. [PMID: 27185320 PMCID: PMC5065399 DOI: 10.1017/s1463423616000165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital. METHODS Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and desire bi-directional communication. Multiple factors influence referral to and acceptance of Access Clinics, but external influences have less impact than expected.
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Affiliation(s)
- Matthew D. Di Guglielmo
- Clinical Assistant Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Jay S. Greenspan
- Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pediatrics, Nemours/Alfred I., duPont Hospital for Children, Wilmington, DE, USA
| | - Diane J. Abatemarco
- Associate Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pediatrics, Nemours/Alfred I., duPont Hospital for Children, Wilmington, DE, USA
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Olin SCS, Kerker B, Stein REK, Weiss D, Whitmyre ED, Hoagwood K, Horwitz SM. Can Postpartum Depression Be Managed in Pediatric Primary Care? J Womens Health (Larchmt) 2015; 25:381-90. [PMID: 26579952 DOI: 10.1089/jwh.2015.5438] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression. METHODS We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting. RESULTS We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices. CONCLUSION Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.
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Affiliation(s)
- Su-Chin Serene Olin
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
| | - Bonnie Kerker
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
| | - Ruth E K Stein
- 2 Albert Einstein College of Medicine/Children's Hospital at Montefiore , Bronx, New York
| | - Dara Weiss
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
| | - Emma D Whitmyre
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
| | - Kimberly Hoagwood
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
| | - Sarah M Horwitz
- 1 Department of Child and Adolescent Psychiatry, New York University School of Medicine , New York, New York
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Abatemarco DJ, Kairys S, Gubernick RS, Hurley T. Using genograms to understand pediatric practices' readiness for change to prevent abuse and neglect. J Child Health Care 2012; 16:153-65. [PMID: 22363045 DOI: 10.1177/1367493511424888] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices' abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs.
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Berger RP, Bazaco MC, Wagner AK, Kochanek PM, Fabio A. Trajectory analysis of serum biomarker concentrations facilitates outcome prediction after pediatric traumatic and hypoxemic brain injury. Dev Neurosci 2010; 32:396-405. [PMID: 20847541 DOI: 10.1159/000316803] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 06/07/2010] [Indexed: 11/19/2022] Open
Abstract
Traumatic brain injury (TBI) and hypoxic ischemic encephalopathy (HIE) are leading causes of morbidity and mortality in children. Several studies over the past several years have evaluated the use of serum biomarkers to predict outcome after pediatric brain injury. These studies have all used simple point estimates such as initial and peak biomarker concentrations to predict outcome. However, this approach does not recognize patterns of change over time. Trajectory analysis is a type of analysis which can capture variance in biomarker concentrations over time and has been used with success in the social sciences. We used trajectory analysis to evaluate the ability of the serum concentrations of 3 brain-specific biomarkers - S100B, neuron-specific enolase (NSE) and myelin basic protein (MBP) - to predict poor outcome (Glasgow Outcome Scale scores 3-5) after pediatric TBI and HIE. Clinical and biomarker data from 100 children with TBI or HIE were evaluated. For each biomarker, we validated 2-, 3- and 4-group models for outcome prediction, using sensitivity and specificity. For S100B, the 3-group model predicted poor outcome with a sensitivity of 59% and specificity of 100%. For NSE, the 3-group model predicted poor outcome with a sensitivity of 48% and specificity of 98%. For MBP, the 3-group model predicted poor outcome with a sensitivity of 73% and specificity of 61%. Thus, when the models predicted a poor outcome, there was a very high probability of a poor outcome. In contrast, 17% of subjects with a poor outcome were predicted to have a good outcome by all 3 biomarker trajectories. These data suggest that trajectory analysis of biomarker data may provide a useful approach for predicting outcome after pediatric brain injury.
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Affiliation(s)
- Rachel Pardes Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, Pittsburgh, PA 15227, USA.
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Abatemarco DJ, Kairys S. Small Changes Can Have Large Impacts: Health Care Overhaul Should Include Child Maltreatment Prevention in Primary Care. Am J Med Qual 2010; 25:334-5. [DOI: 10.1177/1062860610376344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Steven Kairys
- Jersey Shore University, Neptune, NJ, University of Medicine and Dentistry of New Jersey, Newark, NJ
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Goff SL, Holboe ES, Concato J. Pediatricians and physical activity counseling: how does residency prepare them for this task? TEACHING AND LEARNING IN MEDICINE 2010; 22:107-111. [PMID: 20614375 DOI: 10.1080/10401331003656512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE Physical activity (PA) health benefits are clear, yet few children in the United States achieve recommended PA levels. Pediatricians provide PA counseling, but it is not known how residencies prepare trainees for this task. The objective was to determine current training methods for PA counseling in pediatric residency programs. SUMMARY Web-based questionnaire exploring curricular content, barriers to curriculum development, and attitudes/beliefs about the pediatrician's role regarding PA counseling was sent to 192 U.S. pediatric residency directors. There were 115 of 192 (60%) programs that responded. Curricula focused on knowledge-based topics with limited training in counseling skills. Respondents felt PA counseling was important, but few felt they could influence PA. Perceived barriers to curriculum development included lack of space in the curriculum, few trained faculty, and insufficient educational materials. CONCLUSIONS Curricula that include a skills-based component in addition to knowledge attainment may improve pediatricians' PA counseling skills.
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Affiliation(s)
- Sarah L Goff
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts 01199, USA.
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