Principles of Child Health Care Financing

The American Academy of Pediatrics believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality comprehensive health care. Comprehensive, high-quality care addresses issues, challenges, and opportunities unique to children and young adults and addresses the effects of historic and present inequities. All families should have equitable access to professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Payment methodologies should be structured to guarantee the economic viability of the pediatric medical home and of pediatric specialty and subspecialty practices. The recent increase in child uninsurance over the last several years is a threat to the well-being of children and families in the short- and long-term. Deficiencies in plans currently covering insured children pose similar threats. The AAP believes that the United States must not sacrifice recent hard-won gains for our children and that child health care financing should be based on the following guiding principles: (1) coverage with quality, affordable health insurance should be universal; (2) comprehensive pediatric services should be covered; (3) cost sharing should be affordable and should not negatively affect care; (4) payment should be adequate to strengthen family- and patient-centered medical homes; (5) child health financing policy should promote equity and address longstanding health and health care disparities; and (6) the unique characteristics and needs of children should be reflected.

Developing a clinical research infrastructure embedded in an academic medicine center that equitably supports future clinician scientists

Clinical research in academic medical centers can be difficult to conduct and meet enrollment goals. Students under-represented in medicine (URiM) are also under-represented in academic leadership positions and as physician-scientists but are critical to help solve health disparities. Barriers in pursuing medicine as a career may be high for URiM students, therefore it is important to create pre-medicine opportunities accessible to all students interested in healthcare careers. We describe an undergraduate clinical research platform, the Academic Associate (AcA) program, embedded in the medical system that supports clinical research for academic physician scientists and provides students equitable access to experiences and mentoring opportunities. Students have the opportunity of completing a Pediatric Clinical Research Minor (PCRM) degree. This program satisfies many pre-medicine opportunities for undergraduate students, including those URiM, and allows access to physician mentors and unique educational experiences for graduate school or employment. Since 2009, 820 students participated in the AcA program (17.5% URiM) and 235 students (18% URiM) completed the PCRM. Of the 820 students, 126 (10% URiM) students matriculated to medical school, 128 (11%URiM) to graduate school, and 85 (16.5% URiM) gained employment in biomedical research fields. Students in our program supported 57 publications and were top-enrollers for several multicentered studies. The AcA program is cost-effective and achieves a high level of success enrolling patients into clinical research. Additionally, the AcA program provides equitable access for students URiM to physician mentorship, pre-medical experiences, and an avenue to early immersion in academic medicine.

The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort

The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort Study (EWC), a collaborative research design comprising 69 cohorts in 31 consortia, was funded by the National Institutes of Health (NIH) in 2016 to improve children's health in the United States. The EWC harmonizes extant data and collects new data using a standardized protocol, the ECHO-Wide Cohort Data Collection Protocol (EWCP). EWCP visits occur at least once per life stage, but the frequency and timing of the visits vary across cohorts. As of March 4, 2022, the EWC cohorts contributed data from 60,553 children and consented 29,622 children for new EWCP data and biospecimen collection. The median (interquartile range) age of EWCP-enrolled children was 7.5 years (3.7-11.1). Surveys, interviews, standardized examinations, laboratory analyses, and medical record abstraction are used to obtain information in 5 main outcome areas: pre-, peri-, and postnatal outcomes; neurodevelopment; obesity; airways; and positive health. Exposures include factors at the level of place (e.g., air pollution, neighborhood socioeconomic status), family (e.g., parental mental health), and individuals (e.g., diet, genomics).

Population Health in Pediatric Primary Care as a Means to Achieving Child Health Equity

We propose population health as a model of care to advance efforts to achieve child health equity. We use the structure-process-outcome framework to highlight key structures of pediatric population health necessary to catalyze what has been slow progress to date. Using specific ongoing examples, we then show how different models of integrated health care delivery systems align population health structures to enable processes aimed to achieve child health equity. We conclude by highlighting the critical role of committed leadership to drive progress.

Considerations in the Determination of Medical Necessity in Children: Application to Contractual Language

Through this policy statement, the American Academy of Pediatrics advocates that all health care insurers adopt consistent medical necessity definitions that reflect the needs of infants, children, adolescents, and young adults (hereafter noted as "children") as a function of developmental, epidemiologic, dependency, demographic, and cost-related factors that change over the pediatric continuum and that differ from adults. Optimally, the scope of benefits defined in health care contracts should address the complete spectrum of health care needs of children and families, but in reality, many plans offer a limited scope of benefits for children. Even if a proposed intervention falls within the scope of benefits or is not specifically excluded from coverage, the health plan may still deny the intervention. In such cases, contractual language may allow an appeal to succeed if the provider demonstrates medical necessity. With the assistance of experienced pediatric physicians and other providers with pediatric expertise, health care payers and agencies should clearly detail the processes that define, evaluate, and determine medical necessity and through which providers may appeal decisions. A basic requirement for any medical necessity process is the consideration of input from the physician(s) caring for a pediatric patient for whom a medical necessity determination is necessary.

Influences of Chronic Physical and Mental Health Conditions on Child and Adolescent Positive Health

OBJECTIVE

Pediatric positive health refers to children's assessments of their well-being. The purpose of this study was to contrast positive health for children aged 8 to 17 years with and without chronic physical and mental health conditions.

METHODS

Data were drawn from the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) research program. Participants included 1764 children ages 8 to 17 years from 13 ECHO cohorts. We measured positive health using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health and Life Satisfaction patient-reported outcome (PRO) measures. We used multiple regression to examine cross-sectional associations between the PROs and parent-reported health conditions and sociodemographic variables. We defined a meaningful difference in average scores as a PROMIS T-score difference of >3.

RESULTS

The sample included 45% 13 to 17-year-olds, 50% females, 8% Latinx, and 23% Black/African-American. Fifty-four percent had a chronic health condition. Of the 16 chronic conditions included in the study, only chronic pain (β = -3.5; 95% CI: -5.2 to -1.9) and depression (β = -6.6; 95% CI: -8.5 to -4.6) were associated with scoring >3 points lower on global health. Only depression was associated with >3 points lower on life satisfaction (β = -6.2; 95% CI: -8.1 to -4.3). Among those with depression, 95% also had another chronic condition.

CONCLUSIONS

Many children with chronic conditions have similar levels of positive health as counterparts without chronic conditions. The study results suggest that negative associations between chronic conditions and positive health may be primarily attributable to presence or co-occurrence of depression.

Pediatric inpatient hospital care

Pediatrics is a field of medical specialty that focuses on children and their potential to successfully grow and develop into healthy adults. The articles in this special edition of Hospital Practice span a range of issues that affect children and their health care in the inpatient hospital setting, including equity and bias mitigation in health care, efficiency in patient rounding, using patient and family complaints to drive improvement efforts, the diagnostic process and avoiding fundamental diagnostic errors, pediatric palliative care, rapidly identifying and treating sepsis in children, the care and management of children on home ventilation, instituting a rapid response team in the pediatric environment, and quality rating systems for children's hospitals.

Addressing Pain With Inpatient Integrative Medicine at a Large Children's Hospital

BACKGROUND

Pediatric integrative medicine (IM) includes the use of therapies not considered mainstream to help alleviate symptoms such as pain and anxiety. These therapies can be provided in the inpatient setting.

METHODS

This 10-week study involved the integration of acupuncture, biofeedback, clinical hypnotherapy, guided imagery, meditation, and music therapy to address pain in children admitted to a large US children's hospital.

RESULTS

Of 51 patients enrolled, 60% of the patients, 66% of their mothers, and 56% of their fathers used CAM (complementary and alternative medicine) in the preceding 1 year. Although 51 families requested integrative therapies, only 18 patients received them because of inadequate provider availability. All recorded pain scores improved with integrative therapies. One parent reported a possible side effect of irritability in the child after clinical hypnotherapy while 5 children reported opiate side effects. All participating families interviewed responded that IM services helped their child's pain and helped their child's mood, and that our hospital should have a permanent IM consult service.

CONCLUSION

Integrative therapies can be helpful to address pain without significant side effects. Further studies are needed to investigate the integration, cost, and cost-effectiveness of integrative therapies in pediatric hospitals.

Targeted Reforms in Health Care Financing to Improve the Care of Adolescents and Young Adults

Significant changes have occurred in the commercial and government insurance marketplace after the passage of 2 federal legislation acts, the Patient Protection and Affordable Care Act of 2010 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Despite the potential these 2 acts held to improve the health care of adolescents and young adults (AYAs), including the financing of care, there are barriers to achieving this goal. In the first quarter of 2016, 13.7% of individuals 18 to 24 years of age still lacked health insurance. Limitations in the scope of benefits coverage and inadequate provider payment can curtail access to health care for AYAs, particularly care related to sexual and reproductive health and mental and behavioral health. Some health plans impose financial barriers to access because they require families to absorb high cost-sharing expenses (eg, deductibles, copayments, and coinsurance). Finally, challenges of confidentiality inherent in the billing and insurance claim practices of some health insurance plans can discourage access to health care in the absence of other obstacles and interfere with provision of confidential care. This policy statement summarizes the current state of impediments that AYA, including those with special health care needs, face in accessing timely and appropriate health care and that providers face in serving these patients. These impediments include limited scope of benefits, high cost sharing, inadequate provider payment, and insufficient confidentiality protections. With this statement, we aim to improve both access to health care by AYAs and providers' delivery of developmentally appropriate health care for these patients through the presentation of an overview of the issues, specific recommendations for reform of health care financing for AYAs, and practical actions that pediatricians and other providers can take to advocate for appropriate payments for providing health care to AYAs.

The Medical Home Experience of Low-income Children with Non-Urgent Encounters in Acute Care Settings

PURPOSE

Assess relationships between having a medical home and health care-seeking behavior attitudes among parents of low-income children with non-urgent encounters in acute settings (emergency, urgent care centers).

METHODS

We analyzed data from 1,743 publicly insured children within non-urgent encounters. Parents completed surveys assessing medical home access and attitudes regarding health care-seeking behavior. Multivariate logistic regression analyses were conducted to investigate relationships between medical home access and attitudes.

RESULTS

Forty percent of children with non-urgent acute care encounters had medical homes. Having a medical home was positively associated with always calling the doctor before going to acute care settings and preference to take a child to their doctor if the doctor's office was open evenings and weekends.

CONCLUSIONS

Although having a medical home is associated with positive attitudes regarding health care-seeking behavior, it may not suffice to overcome other barriers that precipitate non-urgentencounters.

Chronic Health Conditions, Physical Activity and Dietary Behaviors of Bhutanese Refugees: A Houston-Based Needs Assessment

Bhutanese refugees resettling in the U.S. face many challenges including several related to health and health care. Limited health literacy and the relatively complicated US health care system may contribute to health disparities as well. A health assessment was conducted on adult refugees in Houston, Texas to provide healthcare providers, community organizations, and stakeholders baseline data to plan programs and interventions. A convenience sample of 100 participants had a mean age of 38.37 years, 56 % where males, and almost 80 % did not have high school level education. High blood pressure (27 %), dizziness (27 %), and arthritis (22 %) were the commonly identified chronic health conditions and trouble concentrating (34 %) and fatigue (37 %) were also reported. Sixty-two percent of the respondents reported that they consume recommended servings of fruits and vegetables and 41 %reported that they were currently getting at least 20-30 min of aerobic exercise per day. The assessment concluded with recommendations on how better provide care and services for the refugees.

Principles of Child Health Care Financing

After passage of the Patient Protection and Affordable Care Act, more children and young adults have become insured and have benefited from health care coverage than at any time since the creation of the Medicaid program in 1965. From 2009 to 2015, the uninsurance rate for children younger than 19 years fell from 9.7% to 5.3%, whereas the uninsurance rate for young adults 19 to 25 years of age declined from 31.7% to 14.5%. Nonetheless, much work remains to be done. The American Academy of Pediatrics (AAP) believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality and comprehensive health care, regardless of their or their families' incomes. Public and private health insurance should safeguard existing benefits for children and take further steps to cover the full array of essential health care services recommended by the AAP. Each family should be able to afford the premiums, deductibles, and other cost-sharing provisions of the plan. Health plans providing these benefits should ensure, insofar as possible, that families have a choice of professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Traditional and innovative payment methodologies by public and private payers should be structured to guarantee the economic viability of the pediatric medical home and of other pediatric specialty and subspecialty practices to address developing shortages in the pediatric specialty and subspecialty workforce, to promote the use of health information technology, to improve population health and the experience of care, and to encourage the delivery of evidence-based and quality health care in the medical home, as well as in other outpatient, inpatient, and home settings. All current and future health care insurance plans should incorporate the principles for child health financing outlined in this statement. Espousing the core principle to do no harm, the AAP believes that the United States must not sacrifice any of the hard-won gains for our children. Medicaid, as the largest single payer of health care for children and young adults, should remain true to its origins as an entitlement program; in other words, future fiscal or regulatory reforms of Medicaid should not reduce the eligibility and scope of benefits for children and young adults below current levels nor jeopardize children's access to care. Proposed Medicaid funding "reforms" (eg, institution of block grant, capped allotment, or per-capita capitation payments to states) will achieve their goal of securing cost savings but will inevitably compel states to reduce enrollee eligibility, trim existing benefits (such as Early and Periodic Screening, Diagnostic, and Treatment), and/or compromise children's access to necessary and timely care through cuts in payments to providers and delivery systems. In fact, the AAP advocates for increased Medicaid funding to improve access to essential care for existing enrollees, fund care for eligible but uninsured children once they enroll, and accommodate enrollment growth that will occur in states that choose to expand Medicaid eligibility. The AAP also calls for Congress to extend funding for the Children's Health Insurance Program, a plan vital to the 8.9 million children it covered in fiscal year 2016, for a minimum of 5 years.

Complementary and Alternative Medicine Use in Uninsured Children in Texas

Use of complementary and alternative medicine (CAM) among US children is 12% according to the 2012 National Health Interview Study. Certain pediatric populations have higher CAM use. We studied an uninsured population because limited access to care likely results in higher CAM use. We surveyed 250 uninsured patients in a free pediatric mobile clinic program. In the largely Hispanic population, rate of CAM use in the preceding 12 months was 45% among children and 59% among parents. Ninety-one percent of children who used CAM had parents who used CAM while only 32% of parents used CAM for themselves but did not use CAM for their children ( P < .001). Seven parents (3%) and 4 children (2%) had ever discussed their CAM use with a physician. Since CAM use is significant in this uninsured population and families do not generally discuss CAM with physicians, health care providers must ask about CAM use and provide guidance.

Preparation for Transition to Adult Care Among Medicaid-Insured Adolescents

BACKGROUND

Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular.

METHODS

We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics.

RESULTS

Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition.

CONCLUSIONS

The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.

Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program

BACKGROUND AND OBJECTIVE

Short courses of oral corticosteroid (OCS) medication are recommended for treatment of moderate to severe asthma exacerbations. Concern has been raised about OCS overuse. Our objective is to describe rates of OCS dispensing among children with asthma and factors associated with variation in OCS dispensing.

METHODS

Claims data for children 1 to <18 years of age with an asthma diagnosis between January 2011 and January 2016 were extracted from the computerized databases of Texas Children's Health Plan.

RESULTS

In the years 2011 to 2015, 17.1% to 21.8% of children had an asthma diagnosis. In each of these years 42.1% to 44.2% of these children had ≥1 OCS dispensing. OCS dispensing rates were higher for the children 1 to 4 years of age compared with older children. Repeated OCS dispensing was common, and was most common for children 1 to 4 years of age. Most children with an OCS dispensing (81%-83%) did not have other utilization suggesting poor asthma control (excessive β-agonist refills, emergency department visit, or hospitalization for asthma). OCSs were less commonly prescribed to patients whose primary care provider was a board-certified pediatrician compared with other types of primary care providers. There was large variation in OCS prescribing rates among pediatricians (15%-86%). There were minimal differences in asthma emergency department visits and no differences in hospitalization rates by the pediatrician's OCS dispensing rate quartile.

CONCLUSIONS

The patterns of dispensing observed suggest substantial overprescribing of OCS for children with an asthma diagnosis.

A Survey of School Nurse Emergency Preparedness 2014-2015

Well-prepared school nurses are more likely to handle emergencies properly. Thus, assessing crisis management preparedness is important. In August 2014, a questionnaire was sent to 275 nurses in a large Texas school system to collect data about nurse and school characteristics, emergency frequency and management, and equipment availability. Completed surveys (201, 73%) were analyzed. Fisher's exact test was used to evaluate comparisons among nurses' confidence levels, school characteristics, emergencies, and medical emergency response plans (MERP). Logistic regression was used to estimate associations between characteristics and nurses reporting less confidence. Most respondents were experienced nurses. Shortness of breath was the most common event faced. Odds of less confidence were significantly higher among nurses with <5 years' experience, working at elementary schools, schools without a MERP or where it was not practiced, or caring for <10 schoolchildren weekly. Overall, recommended emergency management guidelines were met.

Survey of Complementary and Alternative Medicine (CAM) Services in Freestanding US Children's Hospitals

Complementary and alternative medicine (CAM) use among US children in 2012 was 11.6%, and studies show CAM use as high as 76% in certain pediatric populations. Children's hospitals offer varied CAM services. This survey aimed to identify CAM services offered, the structure of CAM departments, and supplement use policies in freestanding US children's hospitals. In our survey, 92% of responding children's hospitals offered CAM services, and 38% had hospital-based CAM centers; 60% of responders had policies for supplement use during hospitalization, whereas only 40% had policies for supplement use surrounding surgery. CAM services are widely offered in freestanding US children's hospitals, but most do not have CAM departments. Many hospitals do not have written policies about supplement use. A better understanding of CAM services, programs, and supplement use policies are needed to bring more coordinated services and safer policies to children's hospitals.

Outcomes for Children with Chronic Conditions Associated with Parent- and Provider-reported Measures of the Medical Home

PURPOSE

Assess relationships between having a patient-centered medical home (PCMH) and health care utilization among low-income children with chronic conditions using parent and practice perspectives.

METHODS

We analyzed data from 240 publicly insured children with chronic conditions. Parents completed surveys assessing PCMH access and their child's primary care practice completed the Medical Home Index (MHI) self-assessment. Multivariate negative binomial analyses were conducted to investigate relationships between PCMH and service use.

RESULTS

Parent-report of a usual source of care was associated with lower rates of emergency care (ED) encounters and hospitalizations. Practice report of higher organizational capacity (e.g., communication, staff education) was associated with lower rates of ED visits and hospitalizations. Parent report of a PCMH was positively associated with practice MHI score.

CONCLUSIONS

Among low-income children with chronic conditions, having a usual source of care and higher quality organizational capacity were associated with lower rates of ED visits and hospitalizations.

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study

BACKGROUND

Infants born prematurely or with complex medical problems are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. Using Healthcare Failure Modes and Effects Analysis (HFMEA), we identified a large number of potentially serious error points in this transition of care. PURPOSE To test whether a multifaceted intervention that included a health coach to assist families and an enhanced personal health record to improve the quality of information available to parents and community professionals would decrease adverse events and improve family assessment of the transition.

METHODS

Using a concurrent cohort design, infants in one geographic area (pod) of the intensive care nursery received the intervention; infants in two other pods received routine discharge care. Primary outcomes included deaths, sick visits, unplanned readmissions and missed appointments within 1 month of discharge. The family assessed the transition using a modified version of the Care Transitions Measure.

RESULTS

125 intervention infants (54% boys) and 104 control infants (48% boys) were enrolled over 18 months. The groups were similar in maternal education, insurance status, language spoken and number of adults in the home, birth weight and length of stay. At least one adverse outcome occurred in 63 (50.4%) intervention infants and 56 (53.8%) control infants (p=0.55). At 24–48 h post discharge, caregivers in the intervention group had significantly higher scores on the adapted care transitions measure (3.51 vs 3.27, p<0.0001); however, at 30 days, the difference was no longer significant (3.45 vs 3.40, p=0.27).

CONCLUSIONS

A multicomponent discharge intervention designed to address specific problems identified using HFMEA did not reduce certain adverse outcomes in the post-discharge period.

TRIAL REGISTRATION

NCT01088945.

The Impact of Tobacco Smoke Exposure on Childhood Asthma in a Medicaid Managed Care Plan

BACKGROUND

Tobacco smoke exposure increases breathing problems of children. Texas Children's Health Plan is a Managed Medicaid and Children's Health Insurance Program (CHIP) managed care provider. The aim of this study is to determine associations among tobacco smoke exposure, asthma prevalence, and asthma health-care utilization.

METHODS

Texas Children's Health Plan conducts an annual survey of members who have a physician visit. Questions were added to the survey in March 2010 about asthma and tobacco smoke exposure. Survey results for children < 18 years of age were matched to health plan claims data for the 12 months following the date of the physician visit.

RESULTS

A total of 22,470 parents of unique members/patients from birth to < 18 years of age participated in the survey. More whites than African Americans or Hispanics report that the child's mother is a smoker (19.5% vs 9.1% and vs 2.3%, respectively; P < .001). Compared with children whose mother does not smoke, parent report of asthma diagnosis and claims for dispensing of short-acting beta agonist medication are greater if the mother is a smoker (adjusted OR, 1.20 [95% CI, 1.03-1.40] and 1.24 [95% CI, 1.08-1.42], respectively). In contrast to Medicaid, in which there are no out-of-pocket costs, the CHIP line of business requires copays for ED visits. ED visits are influenced by maternal smoking only in the CHIP line of business (adjusted OR, 4.40; 95% CI, 1.69-11.44).

CONCLUSION

Maternal smoking increases risk for asthma diagnosis and prescription of asthma quick relief medication. Maternal smoking predicted asthma-related ED visits only for the CHIP line of business.

Feasibility of an obesity intervention for paediatric primary care targeting parenting and children: Helping HAND

BACKGROUND

  The primary care setting offers the opportunity to reach children and parents to encourage healthy lifestyle behaviours, and improve weight status among children.

OBJECTIVE

  Test the feasibility of Helping HAND (Healthy Activity and Nutrition Directions), an obesity intervention for 5- to 8-year-old children in primary care clinics.

METHODS

  A randomized controlled pilot study of Helping HAND, a 6-month intervention, targeted children with body mass index 85-99%tile and their parents. Intervention group attended monthly sessions and self-selected child behaviours and parenting practices to change. Control group received regular paediatric care and was wait-listed for Helping HAND. Session completion, participant satisfaction, child anthropometrics, dietary intake, physical activity, TV viewing and behaviour-specific parenting practices were measured pre and post intervention.

RESULTS

  Forty parent-child dyads enrolled: 82.5% were Hispanic, 80% had a girl and 65% reported income ≤ $30, 000/year. There was 20% attrition from Helping HAND (attended <4/6 sessions). Families self-selected 4.35 (SD 1.75) behaviours to target during the 6-month programme and each of the seven behaviours was selected by 45-80% of the families. There were no between group differences in the child's body mass index z-score, dietary intake or physical activity post intervention. Intervention group viewed 14.9 (SE 2.3) h/week of TV post intervention versus control group 23.3 (SE 2.4) h/week (P < 0.05).

CONCLUSION

  Helping HAND is feasible, due to low attrition, good programme attendance, and clinically relevant improvements in some child and parenting behaviours.

Integration of Administrative Data and Chart Review for Reporting Health Care Utilization Among Children With Sickle Cell Disease

Health care utilization of children with sickle cell disease (SCD) has been well documented due to an increase in the use of administrative data sets. While use of such data sources is relatively efficient and low cost, questions remain as to whether they provide sufficient information to fully characterize health care use. The aim of this study was to determine whether administrative data have the capacity to fully assess health care utilization among children with SCD. We studied the health care utilization of 154 low-income children with SCD in a managed care organization combining administrative data and medical record review. In our comparison, we found that administrative claims provided key information on the scope and location of health service use and that sole reliance on medical record review may undercount unique members and encounters.

The dance between attending physicians and senior residents as teachers and supervisors

OBJECTIVE

To examine how attending physicians and senior residents negotiated shared responsibilities for teaching and supervising on clinical work rounds.

METHODS

As part of a larger ethnographic field study, we observed clinical work rounds on a General Pediatrics ward over 8 months, and interviewed 14 of 18 attending physicians and 9 of 11 senior residents whom we observed. Struck by the frequency of 2 codes in that data set ("stand back" and "step up"), we used the metaphor of a dance as an analytic strategy for understanding the dynamic relationship between attending physicians and senior residents.

RESULTS

Like a traditional dance with a priori choreography, and consistent with the traditional premise in graduate medical education, attending physicians frequently "stood back" and senior residents, accordingly, "stepped up" and took on teaching and supervising responsibilities. Less often, both attending physicians and senior residents assumed the lead, or attending physicians stepped up rather than entrust senior residents. The complex clinical context sometimes changed the choreography. Attending physicians and senior residents understood their mutual responsibilities but were not bound by them; they improvised to maintain high-quality patient care.

CONCLUSIONS

The metaphor of a dance enabled us to better understand not only how attending physicians and senior residents negotiate shared responsibilities for teaching and supervision on clinical work rounds, but also how the clinical context impacts this negotiation. A better understanding of this negotiated relationship may help to clarify assumptions and set realistic expectations for what it might take for senior residents to assume progressive responsibility for these responsibilities in today's clinical context.

Qualitative research methods for medical educators

This paper provides a primer for qualitative research in medical education. Our aim is to equip readers with a basic understanding of qualitative research and prepare them to judge the goodness of fit between qualitative research and their own research questions. We provide an overview of the reasons for choosing a qualitative research approach and potential benefits of using these methods for systematic investigation. We discuss developing qualitative research questions, grounding research in a philosophical framework, and applying rigorous methods of data collection, sampling, and analysis. We also address methods to establish the trustworthiness of a qualitative study and introduce the reader to ethical concerns that warrant special attention when planning qualitative research. We conclude with a worksheet that readers may use for designing a qualitative study. Medical educators ask many questions that carefully designed qualitative research would address effectively. Careful attention to the design of qualitative studies will help to ensure credible answers that will illuminate many of the issues, challenges, and quandaries that arise while doing the work of medical education.

Care transitions from inpatient to outpatient settings: ongoing challenges and emerging best practices

Care transitions occur every time a patient changes levels of service, location, or with each shift change or transfer of care. The complexities involved in transitions of care make these time periods particularly susceptible to medical errors, placing patients at risk. Improving care transitions affects all patients in all settings, and has the potential to reduce adverse events, improve quality of care, and produce medical cost savings. This article is a focused review of transitions in care from the inpatient to ambulatory care settings. Underlying challenges and sources of errors are identified, and possible solutions and interventions are explored. Specific challenges to the pediatric population are also examined in detail.

Predictors of direct costs of diabetes care in pediatric patients with type 1 diabetes

OBJECTIVE

This study examines factors that predict elevated direct costs of pediatric patients with type 1 diabetes.

METHODS

A cohort of 784 children with type 1 diabetes at least 6 months postdiagnosis and managed by pediatric endocrinologists at Texas Children's Hospital were included in this study. Actual reimbursed costs from January 2004 to December 2005 were obtained. Medication and supply costs were based on estimates from insulin dosage and type of insulin regimen prescribed, respectively. We examined utilization of care, total diabetes-related direct medical costs, and predictors of direct costs and hospitalization.

RESULTS

Annually, 7% (58/784) of patients (excluding initial hospitalization at diagnosis) had a diabetes-related hospitalization and median length of stay was days. Mean total diabetes-related direct cost per person-year was $4730 [95% confidence interval (CI), 4516-4944]. Supplies accounted for 38% and medications 33% of costs, respectively. Older age, hemoglobin A(1C) (HbA(1C) ) > 8.5%, use of a multi-injection or pump regimen, living in a non-married household, and female gender were associated with higher annual costs. HbA(1C) > 8.5%, living in a non-married household, and female gender increased the odds of a diabetes-related hospitalization.

DISCUSSION

Better metabolic control in patients with type 1 diabetes was associated with lower direct medical costs and lower odds of hospitalization. Marital status of the primary caregiver, irrespective of type of insurance, impacts the patient's healthcare costs and risk of hospitalization. This large single-center US study analyzes cost distribution in children with diabetes and is informative for payers and providers focused on effective management and improving healthcare costs.

Bleeding disorder education in obstetrics and gynecology residency training: a national survey

STUDY OBJECTIVE

The purpose of this study was to assess the educational approach to the bleeding disorder evaluation in Obstetrics and Gynecology residency training programs in the continental United States. Information was sought from chief residents regarding training experiences and fund of knowledge regarding the evaluation of menorrhagia and diagnosis of bleeding disorders during their residency.

DESIGN

A 24-item questionnaire was sent to the chief residents at 241 non-military Obstetrics and Gynecology residency programs.

SETTING

The study was conducted at Texas Children's Health Plan in Houston, Texas.

PARTICIPANTS

Chief residents at 241 non-military Obstetrics and Gynecology residency programs.

MAIN OUTCOME MEASURES

Responses to questionnaires.

RESULTS

The overall response rate was 30%. Residents reported training in the medical evaluation of menorrhagia during residency with a mean of 9.1 hours per year in the first year of residency and 11.1 hours/year in the 2(nd), 3(rd) and 4(th) years; 67.7% reported they viewed their training in the medical evaluation of menorrhagia and bleeding disorders as sufficient preparation for clinical practice; and over two thirds reported specific training in common bleeding disorders, such as von Willebrand disease.

CONCLUSION

The current state of training in the evaluation of menorrhagia and bleeding disorders appeared to be mixed regarding the evaluation of dysfunctional uterine bleeding. An area for improvement was identified to better approach best clinical practice in the evaluation of women with menorrhagia and underlying bleeding disorders, which can be guided by the thoughtful approach taken in the recent NHLBI von Willebrand disease guidelines.

An ethnographic study of attending rounds in general paediatrics: understanding the ritual

OBJECTIVES

Teaching at the bedside during attending rounds is considered to be fundamental to medical education. We conducted an ethnographic case study to investigate such teaching in general paediatrics as a social phenomenon and to explore change over time in both the meaning of rounds and the context in which rounds take place.

METHODS

We conducted a case study from January to August 2006 on a 22-bed general paediatric unit in an urban children's hospital and focused our observation on interns, senior residents and attending physicians. We observed the medical team during its normal activities on the study unit and conducted semi-structured interviews with a sample of attendings, interns and senior residents. We compiled a list of codes that emerged from patterns in the data and constructed a rich description of rounds according to the principles of inductive analysis.

RESULTS

Four themes emerged from the data: (i) attending rounds are a pervasive and routine part of clinical education; (ii) interns, senior residents and attending physicians hold assumptions about what should happen on rounds; (iii) tension exists between interns', senior residents' and attending physicians' assumptions about bedside teaching during rounds and the reality imposed by contextual factors, and (iv) bedside teaching during rounds is impacted, but not prohibited, by contextual factors.

CONCLUSIONS

Our case study provides evidence that bedside teaching during rounds is a pedagogical ideal entrenched in medical education. Participants readily acknowledged teaching at the bedside during rounds as something they perceived should happen, although, in actuality, it was infrequently achieved. This study revealed a telling inconsistency in language and behaviour: 'bedside rounds' was embedded in the participants' ordinary language, but the activity was not necessarily part of their ordinary behaviour. We propose that the practice of bedside teaching is best explained as a ritual. Considering bedside teaching as a ritual helps to explain why rounds are sacrosanct and helps to develop more appropriate expectations for rounds.

"Just be respectful of the primary doc": teaching mutual respect as a dimension of teamwork in general pediatrics

OBJECTIVE

Although others have reported on teamwork training, little is known about what pediatric residents in inpatient settings learn implicitly about respectful working relationships with community-based general pediatricians. The purpose of this brief report is to examine how pediatric residents on an inpatient general pediatric rotation regard "the other" (community-based general pediatricians), and how academic, hospital-based general pediatric attending physicians respond.

METHODS

We conducted a case study on one general pediatrics floor, which entailed 143 hours of observation over 8 months (January to August 2006), as well as in-depth interviews with 25 residents and 14 general pediatric attending physicians whom we observed as they worked on the floor. Data were derived from >1000 pages of field notes and interview transcripts. We systematically reviewed the data and inductively derived codes related to explicit and implicit education. In this brief report, we focused our analysis on data relevant to the concept of boundary crossing: when members of the group talk about members of another group in the process of inquiring about or negotiating patient care.

RESULTS

Residents' comments tended to reveal a neutral or somewhat negative regard for their general pediatric community counterparts, whom they typically referred to as PMDs (primary medical doctors). Attending physicians' responses to these comments varied, but often explicitly taught residents about dimensions of teamwork, including mutual respect.

CONCLUSIONS

Explicit teamwork training in pediatric education should not be limited to partnering with other disciplines or other specialties, but expanded to enhance positive regard and mutual respect for general pediatricians in hospital- and community-based settings alike. Attending physicians in general pediatrics are ideally positioned to implicitly teach respectful working relationships within the specialty.

Mental health referral and services for maltreated children and child protection evaluations of children with special needs: a national survey of hospital- and community-based medically oriented teams

OBJECTIVE

To survey the self-perceived capability of medically oriented child maltreatment teams in the US to provide mental health referrals and services when needed and to evaluate children with special health care needs (CSHCN).

METHODS

Mailed questionnaire with 5 items related to mental health, 12 items on services for CSHCN, and 28 items on financial issues previously reported.

RESULTS

Responses were received from 320 of 472 organizations (67.8%); 153 respondents had at least 1 physician or nurse practitioner and were included in the analysis; 91 were hospital-based teams (HBTs); and 62 were community-based teams (CBTs). CBTs were significantly more likely to offer mental health treatment (65.0% vs 35.6%). When mental health services were needed in another language, only half (50.7%) indicated that services were available in Spanish, less than a third (29.3%) could find services in sign language, and only 20.3% expected to find services for patients who used other languages. Of all children evaluated, 31.2% had special health care needs. CBTs reported seeing significantly more CSHCN than HBTs (38.3% vs 26.5%). Over two-thirds (67.7%) did not have a special program or specialized staff to serve CSHCN. Overall, teams had some training and experience with CSHCN. Children who were deaf were evaluated by 84.5% of teams, while only 50.5% reported using professionally trained sign language interpreters. Most teams (82.2%) indicated that more time was needed to evaluate CSHCN, and 69.1% found arranging for mental health treatment for CSHCN more difficult than children without special needs.

CONCLUSIONS

Medically oriented child maltreatment teams are generally able to arrange for mental health services for the children served, and most feel capable of serving CSHCN. Significantly more mental health service providers are needed for children and families who communicate in languages other than English (e.g., Spanish, American Sign Language [ASL]).

PRACTICE IMPLICATIONS

Our results suggest that medically oriented child maltreatment teams and mental health services for maltreated children would improve gaps in services by: (1) recruiting and training bilingual professionals, (2) ensuring that children or family members who are deaf receive professional ASL services, and (3) ensuring that training is provided related to the needs of CSHCN.

Do pediatric chief residents recognize details of prepubertal male genital anatomy

This study evaluates how well pediatric chief residents can label anatomic structures, recognize circumcision, and discern abnormal anatomy on three photographs of male pre-pubertal genitalia. Additionally, this study explored aspects of pediatric training in sexual abuse and clinical practice issues regarding routine genital examination of a male patient. We asked respondents to identify anatomic structures, recognize circumcision, and assign a Tanner stage to pre-pubertal male genitalia and to recognize an abnormal finding. 92.7% of chief residents were able to correctly identify basic structures on the photo of a circumcised pre-pubertal male. Only 22% correctly recognized the abnormal example as hypospadias. Basic recognition of anatomic structures and circumcision did not achieve 100% accuracy, while an abnormal condition was missed by the majority of respondents. These data suggest a need to address education about the male genital exam in greater detail during pediatric residency training.

Results of a multifaceted Intimate Partner Violence training program for pediatric residents

OBJECTIVE

To evaluate the efficacy of a multifaceted Intimate Partner Violence (IPV) intervention on knowledge, attitudes, and screening practices of pediatric residents.

METHODS

The intervention included: an on-site IPV counselor, IPV training for attending physicians, residents and social workers, and screening prompts. Evaluation included baseline and post-training surveys of residents, assessing their knowledge, attitudes, and comfort with IPV screening, patient chart reviews at baseline, 3 months, and 8 months for documentation of IPV screening, and review of the IPV counselor's client charts.

RESULTS

Baseline chart review showed screening rates of less than 1%. Screening rates were 36.2% at 3 months and 33.1% at 8 months. After training, residents were more likely to know: IPV screening questions (47.1% vs. 100%); referral sources (34.3% vs. 82.9%); and the relationship between child abuse and IPV (52.9% vs. 97.1%). At baseline, barriers to IPV screening included time (50%), lack of knowledge of how to screen (26.5%) and where to refer (23.5%). Post-training, barriers were time (44%), presence of children (25.9%) or other adults (18.5%) in the room, and inappropriate location (18.5%). Post-training, none of the residents listed "lack of knowledge" or "lack of referral sources" as barriers to IPV screening. After 12 months, 107 victims of IPV were identified; most referred from inpatient units and subspecialty clinics.

CONCLUSION

A multifaceted IPV intervention increased identification of IPV victims and markedly improved attitudes, comfort, and IPV screening practices of pediatric residents. IPV screening rates were sustainable with minimal ongoing training.

PRACTICE IMPLICATIONS

Consideration should be given to the training and practice supports necessary to encourage IPV screening in the pediatric setting. Educational efforts that familiarize pediatricians with the content surrounding the risk and potential impact of IPV to children and families along with practice supports that make incorporating screening for IPV as easy as possible have the potential to increase the identification of this problem and promote referrals to IPV agencies for follow-up and intervention where needed.

Parenting stress in US families: implications for paediatric healthcare utilization

OBJECTIVE

According to family stress models, parental responses to stress disrupt interactions between parent and child and may lead to parental inability to seek timely medical care for their child. The objective of this study was to quantitatively assess the relationship between high parenting stress and child healthcare utilization.

METHODS

We used the 2003-2004 National Survey of Children's Health to determine the prevalence of parenting stress in US families and associated socio-demographic variables. We used weighted logistic regression to investigate associations between parenting stress and healthcare utilization, controlling for other parental psychosocial and socio-demographic variables. The primary independent variables were parenting stress, parental mental health, parental coping and social support. The main dependent variables were emergency care, sick visits to primary care and preventive care in the past 12 months.

RESULTS

Nationally, 13% of children lived in households with at least one parent experiencing high parenting stress. Socio-demographic variables associated with the highest odds of parenting stress included Black race, special needs status and non-English primary language. Parents with high parenting stress had a higher odds (adjusted odds ratio 1.24, 95% confidence interval 1.10-1.41) of seeking emergency care for their children compared with parents with low parenting stress, controlling for other parental psychosocial factors and socio-demographic variables.

CONCLUSIONS

Having a parent who is experiencing high parenting stress is associated with greater utilization of paediatric emergency care. Interventions targeted at parenting stress may provide families with needed support and reduce unnecessary emergency care utilization.

Parenting stress in US families: implications for paediatric healthcare utilization

OBJECTIVE

According to family stress models, parental responses to stress disrupt interactions between parent and child and may lead to parental inability to seek timely medical care for their child. The objective of this study was to quantitatively assess the relationship between high parenting stress and child healthcare utilization.

METHODS

We used the 2003-2004 National Survey of Children's Health to determine the prevalence of parenting stress in US families and associated socio-demographic variables. We used weighted logistic regression to investigate associations between parenting stress and healthcare utilization, controlling for other parental psychosocial and socio-demographic variables. The primary independent variables were parenting stress, parental mental health, parental coping and social support. The main dependent variables were emergency care, sick visits to primary care and preventive care in the past 12 months.

RESULTS

Nationally, 13% of children lived in households with at least one parent experiencing high parenting stress. Socio-demographic variables associated with the highest odds of parenting stress included Black race, special needs status and non-English primary language. Parents with high parenting stress had a higher odds (adjusted odds ratio 1.24, 95% confidence interval 1.10-1.41) of seeking emergency care for their children compared with parents with low parenting stress, controlling for other parental psychosocial factors and socio-demographic variables.

CONCLUSIONS

Having a parent who is experiencing high parenting stress is associated with greater utilization of paediatric emergency care. Interventions targeted at parenting stress may provide families with needed support and reduce unnecessary emergency care utilization.

Respiratory syncytial virus prevention outreach project

The objective of the study is to determine whether early identification, outreach, and intervention would increase compliance with palivizumab prophylaxis for respiratory syncytial virus prevention for members of a Texas Medicaid managed care organization. The study cohort was selected from administrative claims data. The observational study period ran from October 1, 2006, to March 31, 2007. Letters, educational materials, and postcards were mailed and outbound telephone calls were placed to qualified members. In addition, letters were sent to primary care providers. Of the 1236 identified members, the 2,238 letters, educational materials, and reminder postcards mailed resulted in 1091 injections to 394 identified members. Only 10% of the 394 members completed their qualified doses as suggested by the guideline. Even with the most intensive outreach, compliance is not highly assured. We must explore other strategies to overcome barriers in this preventive medicine program.

Implicit versus explicit curricula in general pediatrics education: is there a convergence?

OBJECTIVE

To describe and analyze the implicit curriculum of a general pediatrics inpatient setting and to understand how it maps onto competency-based goals and objectives in the explicit curriculum.

METHODS

We conducted a case study on a general pediatrics floor, which entailed 143 hours of direct observation during 8 months and 39 in-depth interviews with pediatric residents and General Pediatric attendings who were observed on multiple occasions as they worked on the floor. Data were derived from field notes and interview transcripts. We inductively coded the data, clustered it according to competency domains, and systematically inspected it to derive themes about the convergence of the implicit and explicit curricula.

RESULTS

The implicit curriculum, shaped by ordinary events, activities, and conversations, taught residents "how things work." The implicit curriculum aligned well with the competency-based goals and objectives in the explicit curriculum; residents had frequent opportunities to meet >90% (29 of 32) of the written objectives. Nonetheless, no one referred to the explicit curriculum or to the competency domains throughout the study. In contrast to the neat list of goals and objectives in the explicit curriculum, the implicit curriculum was extraordinarily messy and dominated by 1 competency domain: patient care. Moreover, the implicit curriculum was not formally recognized as integral to a competency-based model of education.

CONCLUSIONS

Representing the competency domains in ways that better reflect how learning opportunities in the implicit curriculum align with the goals and objectives in the explicit curriculum may increase awareness of the full range of residents' learning experiences.

Association of medical home care and disparities in emergency care utilization among children with special health care needs

OBJECTIVE

The aim of this study was to determine whether having a medical home is associated with a reduction of racial/ethnic disparities in emergency care utilization by children with special health care needs (CSHCN).

METHODS

We conducted a secondary analysis of 35 301 children, aged 0 to 17, from the 2005-2006 National Survey of Children with Special Health Care Needs. The primary dependent variable was emergency care utilization, defined as 1 or more emergency care encounters in the last 12 months. The primary independent variables were race/ethnicity and type of care (medical home, usual source of care, no medical home/no usual source of care). Multiple logistic regression was conducted to investigate associations between race/ethnicity, type of care, and emergency care utilization.

RESULTS

Analysis of type of care and its interactions with race/ethnicity showed that non-Hispanic black children with a medical home had higher odds (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.03-1.54) of emergency care utilization compared with non-Hispanic white children with a medical home. The odds of having 1 or more emergency care visits were higher for non-Hispanic black children (OR 1.38, 95% CI 1.22-1.56) compared with non-Hispanic white children after controlling for sociodemographic variables. Having a medical home was associated with lower odds of emergency care utilization (OR 0.81, 95% CI 0.72-0.90) compared with having neither a medical home nor a usual source of care.

CONCLUSIONS

Emergency care utilization for CSHCN differed significantly according to race/ethnicity. Having a medical home may be associated with a reduction in disparities in this fragile population.

Racial and ethnic disparities in indicators of a primary care medical home for children

OBJECTIVE

Racial/ethnic disparities in access to care across a broad range of health services have been well established. In adults, having a medical home has been shown to reduce disparities. The objective of this study was to assess the extent to which children of different race/ethnicities receive primary care consistent with a medical home.

METHODS

We conducted a secondary analysis of 84 101 children, ages 0-17, from the 2003-2004 National Survey of Children's Health, a nationwide household survey. The primary independent variable was race/ethnicity of the child. The main dependent variable was a medical home as defined by the American Academy of Pediatrics. Multiple logistic regression was conducted to investigate associations between race/ethnicity and having a medical home.

RESULTS

The odds of having a medical home were lower for non-Hispanic black (odds ratio [OR] 0.76, 95% confidence interval [95% CI] 0.69-0.83), Hispanic (OR 0.80, 95% CI 0.72-0.89), and other (OR 0.77, 95% CI 0.69-0.87) children compared with non-Hispanic white children after adjusting for sociodemographic variables. Specific components of a medical home for which minority children had a lower odds (P < .01) of having compared with white children included having a personal provider, a provider who always/usually spent enough time with them, and a provider who always/usually communicated well.

CONCLUSIONS

Minority children experienced multiple disparities compared with white children in having a medical home. Study of individual medical home components has the potential to identify specific areas to improve disparities.

Healthcare utilization and expenditures for low income children with sickle cell disease

BACKGROUND

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low-income children with SCD in comparison to other children of similar socioeconomic status.

PROCEDURE

For the study period, 2004-2007, we conducted a retrospective, cross-sectional descriptive analysis of administrative claims data from a managed care plan exclusively serving low-income children with Medicaid and the State Children's Health Insurance Plan (SCHIP). Patient demographics, continuity of insurance coverage, healthcare utilization, and expenditures were collected for all children enrolled with SCD and the general population within the health plan for comparison.

RESULTS

On average, 27% of members with SCD required inpatient hospitalization and 39% utilized emergency care in a given calendar year. Both values were significantly higher than those of the general health plan population (P < 0.0001). Across the study period, 63% of members with SCD averaged one well child check per year and 10% had a minimum of one outpatient visit per year to a hematologist for comprehensive specialty care.

CONCLUSIONS

Low-income children with SCD demonstrate significantly higher healthcare utilization for inpatient care, emergency center care, and home health care compared to children with similar socio-demographic characteristics. A substantial proportion of children with SCD may fail to meet minimum guidelines for outpatient primary and hematology comprehensive care.

Understanding paediatric resident-continuity preceptor relationships through the lens of apprenticeship learning

CONTEXT

Apprenticeship learning is common in medical education, but is often situated in theoretical frameworks which highlight its cognitive but not its social dimension.

METHODS

We conducted an ethnographic case study of paediatric residents' learning relationships with their preceptors in a community-based paediatric continuity site. It included 5 months (100 hours) of direct observation, and semi-structured interviews with 10 residents (before and after observation) and 10 primary care paediatricians who served as their continuity preceptors (after observation). Interview transcripts and notes from observations were inductively coded and analysed for major themes.

RESULTS

Our observations and reports of resident learning trajectories fit well with the concept of legitimate peripheral participation. Residents learned the everyday practice of primary care as they worked alongside experienced paediatricians in the continuity clinic. Although the direction of learning was towards central participation in patient care, residents learned during transient shifts to the periphery of practice. As a function of residents' increased participation, preceptors moved into more supportive roles. Residents were not only learners; at times they were teachers who facilitated preceptors' learning.

CONCLUSIONS

Legitimate peripheral participation is a concept that helps to explain apprenticeship as a dynamic social relationship which shapes, and is shaped by, learning that takes place in clinical practice. Other concepts shed light on the bidirectional nature of apprenticeship learning.

Learning behind the scenes: perceptions and observations of role modeling in pediatric residents' continuity experience

OBJECTIVE

Little is known about what residents learn from "everyday" physician role models, who, in the course of their ordinary work, serve as real-life examples of residents' future roles. The purpose of this research was to analyze what and how pediatric residents learn through role modeling during their continuity experience.

DESIGN

We conducted a case study of 10 third-year pediatric residents and their 10 continuity clinic preceptors (CCP) in a community-based continuity clinic. Data were derived from 5 months (100 hours) of direct observation in clinic; semistructured interviews with residents before and after observation; and semistructured interviews with CCPs after resident data were collected. Interview transcripts and notes from observation were inductively coded and thematically analyzed.

RESULTS

From the residents' perspective, role modeling was an implicit and intentional learning strategy that was linked to routine clinical practice in continuity clinic. Residents learned, through modeling their CCPs, "how to talk" and "how to think things through." Residents did not directly report modeling professional behavior. For residents, learning through modeling was not contingent on CCPs' awareness of being a role model.

CONCLUSIONS

Role modeling is a nuanced, deliberate learning strategy that provides pediatric residents with templates for interpersonal communication and clinical decision making that have both immediate and long-term relevance. Understanding residents' perspective on role modeling, and how it aligns with their CCPs' perspective, presents opportunities for improving residents' learning experiences, faculty development, and future research.