Caring for screenagers (part 2): a pediatrician's primer on popular games and educational tools

PURPOSE OF REVIEW

The internet has changed the way children can work and play. With the preferences of the youth population constantly evolving, it is important that parents and pediatricians continue to be informed of the ways children spend their time on the internet. Online gaming continues to soar in popularity, as does school usage of educational platforms.

RECENT FINDINGS

Roblox, Fortnite, and Minecraft are three examples of games that have widespread popularity among youth populations. Though none of the game are designed to display graphic violence, sexual content, or other features that could be considered off-limits for children, there still ways for children to exposed to inappropriate material or engage with strangers. The rise in popularity of eSports also reflects changing attitudes about the value of gaming. On the educational side, school-student platforms and powerful artificial intelligence (AI) tools are becoming more and more prevalent.

SUMMARY

Parents should not simply know which games or educational tools their children are using, but understand them. This article seeks to provide some insight into popular games and platforms so that parents and pediatricians can make better decisions about what children access.

Use of a serious game simulation to build early childhood staff capacity for reducing unintentional childhood injuries

INTRODUCTION

Unintentional home injuries are common and costly, with over 1.6 million occurring among U.S. children ages 0-4 in 2018. Home visitors and other early childhood professionals can provide valuable prevention education and intervention to reduce unintentional injury risk for children. This proof-of-concept study aimed to test the feasibility of the first phase of Home Safety Hero, a software-based serious game simulation that trains users in identification of home safety risks, as a capacity building tool for early childhood professionals.

METHODS

The game simulation's potential for knowledge promotion and engagement in a sample of home visitors was explored based on play of the first phase. Repeated measures ANOVAs were used to assess learning via reaction time, and engagement was measured via the User Engagement Scale (UES).

RESULTS

Reaction time (i.e., average time to identify hazards) improved from the first to last levels in both single and mixed category levels in this trial. Participant indicated agreement with four subscales of engagement measured by the UES, and neutral to agree on a fifth subscale, focused attention.

CONCLUSIONS

We propose that this game simulation can meet the unique training needs of early childhood professionals while promoting home safety knowledge that can improve prevention work with families. Participant feedback was largely positive, and results suggest that the game simulation is engaging and contributes to knowledge.

PRACTICAL APPLICATIONS

The Home Safety Hero serious game simulation is a flexible training option that appeared to be feasible for reducing time to hazard identification among home visitors in this proof-of-concept study. The design of the game simulation has utility in meeting the specialized training needs of early childhood professionals and potential to build their capacity to provide direct intervention around home safety, reducing risk for unintentional injury among children.

Paediatric surgical response to an 'adult' COVID-19 pandemic

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) has dramatically affected global healthcare systems. We aimed to determine the response of our paediatric surgical fraternity to a disease that overwhelmingly affects adults.

MATERIALS AND METHODS

We conducted a cross-sectional questionnaire-based study over 6 weeks during a federally mandated lockdown. Using snowball sampling, we recruited paediatric surgeons, trainees and medical officers from paediatric surgical units in Malaysia. The anonymous online questionnaire covered sociodemographic information, changes in patient care, redeployment, concerns regarding family members, and impact on training. Mental well-being was assessed using the Depression, Anxiety and Stress Scale (DASS-21). Kruskal-Wallis, ANOVA and multiple regression analysis was used, with significance level 0.05.

RESULTS

Of the 129 eligible participants, 100(77%) responded. Junior doctors had clinically higher levels of depression, anxiety, and stress. Age <30 years was significantly associated with anxiety. Junior doctors believed that redeployment led to loss of surgical skills (p<0.001) and trainees felt that clinical application of knowledge had reduced (p<0.020).

CONCLUSION

Specific to our paediatric surgical community, this study highlights areas of concern, particularly among junior doctors. It is likely that recurrent cycles of the pandemic will occur soon. These issues must be addressed to preserve the mental and emotional well-being of all health care workers.

A novel faculty development tool for writing a letter of recommendation

Objective

Based on a national survey of program directors we developed a letter of recommendation (LOR) scoring rubric (SR) to assess LORs submitted to a pediatric residency program. The objective was to use the SR to analyze: the consistency of LOR ratings across raters and LOR components that contributed to impression of the LOR and candidate.

Methods

We graded 30 LORs submitted to a pediatric residency program that were evenly distributed based on final rank by our program. The SR contained 3 sections (letter features, phrases, and applicant abilities) and 2 questions about the quality of the LOR (LORQ) and impression of the candidate (IC) after reading the LOR on a 5-point Likert scale. Inter-rater reliability was calculated with intraclass correlation coefficients (ICC(2,1)). Pearson (r) correlations and stepwise multivariate linear regression modeling predicted LORQ and IC. Mean scores of phrases, features, and applicant abilities were analyzed with ANOVA and Bonferroni correction.

Results

Phrases (ICC(2,1) = 0.82, p<0.001)) and features (ICC(2,1) = 0.60, p<0.001)) were rated consistently, while applicant abilities were not (ICC(2,1) = 0.28, p<0.001)). For features, LORQ (R² = 0.75, p<0.001) and IC (R² = 0.58, p<0.001) were best predicated by: writing about candidates’ abilities, strength of recommendation, and depth of interaction with the applicant. For abilities, LORQ (R² = 0.47, p<0.001) and IC (R² = 0.51, p<0.001) were best predicted by: clinical reasoning, leadership, and communication skills (0.2). There were significant differences for phrases and features (p<0.05).

Conclusions

The SR was consistent across raters and correlates with impression of LORQ and IC. This rubric has potential as a faculty development tool for writing LORS.

The impact of pulse oximetry and Integrated Management of Childhood Illness (IMCI) training on antibiotic prescribing practices in rural Malawi: A mixed-methods study

BACKGROUND

The misdiagnosis of non-malarial fever in sub-Saharan Africa has contributed to the significant burden of pediatric pneumonia and the inappropriate use of antibiotics in this region. This study aims to assess the impact of 1) portable pulse oximeters and 2) Integrated Management of Childhood Illness (IMCI) continued education training on the diagnosis and treatment of non-malarial fever amongst pediatric patients being treated by the Global AIDS Interfaith Alliance (GAIA) in rural Malawi.

METHODS

This study involved a logbook review to compare treatment patterns between five GAIA mobile clinics in Mulanje, Malawi during April-June 2019. An intervention study design was employed with four study groups: 1) 2016 control, 2) 2019 control, 3) IMCI-only, and 4) IMCI and pulse oximeter. A total of 3,504 patient logbook records were included based on these inclusion criteria: age under five years, febrile, malaria-negative, and treated during the dry season. A qualitative questionnaire was distributed to the participating GAIA providers. Fisher's Exact Testing and odds ratios were calculated to compare the prescriptive practices between each study group and reported with 95% confidence intervals.

RESULTS

The pre- and post-exam scores for the providers who participated in the IMCI training showed an increase in content knowledge and understanding (p<0.001). The antibiotic prescription rates in each study group were 75% (2016 control), 85% (2019 control), 84% (IMCI only), and 42% (IMCI + pulse oximeter) (p<0.001). An increase in pneumonia diagnoses was detected for patients who received pulse oximeter evaluation with an oxygen saturation <95% (p<0.001). No significant changes in antibiotic prescribing practices were detected in the IMCI-only group (p>0.001). However, provider responses to the qualitative questionnaires indicated alternative benefits of the training including improved illness classification and increased provider confidence.

CONCLUSION

Clinics that implemented both the IMCI course and pulse oximeters exhibited a significant decrease in antibiotic prescription rates, thus highlighting the potential of this tool in combatting antibiotic overconsumption in low-resource settings. Enhanced detection of hypoxia in pediatric patients was regarded by clinicians as helpful for identifying pneumonia cases. GAIA staff appreciated the IMCI continued education training, however it did not appear to significantly impact antibiotic prescription rates and/or pneumonia diagnosis.

Addressing Firearm Safety Counseling: Integration of a Multidisciplinary Workshop in a Pediatric Residency Program

BACKGROUND

Firearm-related injuries are the second leading cause of death among US children. Given this, firearm injury prevention should be a key aspect of pediatric anticipatory guidance.

OBJECTIVE

We assessed the impact of a firearm safety counseling workshop on pediatric resident knowledge, self-efficacy, and self-reported practice patterns.

METHODS

Sixty of 80 residents (75%) participated in a 2-hour multimodal workshop, including video, didactics with experts, and role-play scenarios. Participants were invited to complete pre-workshop, immediate post-workshop, and 3- and 6-month post-workshop self-reported questionnaires evaluating knowledge, comfort, perceived barriers, and reported practice patterns. Data comparing pre- and 6-month post-workshop practice patterns were analyzed via Fischer's exact test. Remaining statistical analysis utilized a one-sided, unpaired Mann-Whitney U test. A binomial exact proportions test was used for open-ended responses.

RESULTS

After the workshop, the percentage of participants with perceived concern regarding parental barriers decreased significantly (24% to 7%, P = .001). Participants 6 months post-workshop were 5.14 times more likely to counsel their patients on firearms during more than 75% of their well visits than prior to the intervention (P = .010). Participants reported greater comfort asking patients about firearms, with mean Likert scores increasing from 3.81 pre to 4.33 post (P = .022), which was similar to 3-month (4.39, P = .06) and 6-month evaluations (4.54, P = .003).

CONCLUSIONS

Education on firearm safety counseling improved pediatric resident comfort level in discussing the topic. This impact persisted 6 months after the workshop, implying a sustained change in attitudes and behaviors.

Early Detection and Diagnosis of Autism Spectrum Disorder: Why Is It So Difficult?

Autism spectrum disorder (ASD) affects approximately 2% of children in the United States (US). Therapeutic interventions are most effective if applied early, yet diagnosis often remains delayed, partly because the diagnosis is based on identifying abnormal behaviors that may not emerge until the disorder is well established. Universal screening has been recommended by the America Academy of Pediatrics at 18 and 24 months yet studies show low compliance by pediatricians and the US Preventive Services Task Force does not support universal screening. To better understand the limitations of universal screening this article looks at the performance of screening tests given the prevalence of ASD. Specifically, although the sensitivity and specificity of the Modified Checklist for Autism in Toddlers, Revised with Follow-up, the de facto screening tool, exceeds 90%, the relatively low prevalence of ASD in the general population (∼2%) results in a positive predictive value of about 33%, resulting in only 1 of 3 children identified by the Modified Checklist for Autism in Toddlers, Revised with Follow-up actually having ASD. To mitigate this issue, the America Academy of Pediatrics has recently recommended the use of a Level 2 screener after failing a Level 1 screener, before referring children on for a full comprehensive evaluation for ASD. In this way, a series of screening tools are used to enrich the population of children referred for further evaluation so fewer without an ASD diagnosis are evaluated. We have developed a program to train pediatricians to utilize these instruments as well as learn to diagnose ASD so children can effectively be referred for appropriate services at the front lines. Given the current burden on the medical system with the diagnosis and evaluation of children with ASD, it is important to create efficient systems for screening children which can best identify those most likely to have ASD. Developing methods to identify those children most at risk for developing ASD, either through consideration of medical or family history or through the use of biomarkers, may be helpful in identifying the children that require increased surveillance and those that do not need screening.

Paediatric/congenital cardiology physician scientists-An endangered species

Producing excellent physician scientists starts with the active discovery of talent and dedication, supported by the strong belief that physician involvement in biomedical research is essential to make fundamental discoveries that improve human health. The revolution of surgical and interventional therapy of structural heart disease has had 'profoundly positive effects on survival and quality of life over the decades. (…) Small increments in clinical improvement will still be possible in the future, but for the most part, the potential for major advancement using these techniques has been exhausted' (Frank Hanley, MD; Stanford). Personalized medicine, rapid genetic diagnostics, RNA and extracellular vesicle biology, epigenetics, gene editing, gene and stem cell-derived therapy are exemplary areas where specialized training for paediatric/congenital cardiology physician scientists will be increasingly needed to further advance the field. About a decade ago, a series in Circulation discussed academic career models and highlighted the major challenges facing the cardiovascular 'clinician scientist' (syn. physician scientist), which have not abated since. To develop the skills and expertise in both clinical congenital cardiology and basic research, the training of fellows must be focused and integrated. The current pandemic COVID-19 puts additional pressure and hurdles on fellows-in-training (FIT) and early career investigators (ECI) who aim to establish, consolidate or expand their own research group. Here, we discuss the major challenges, opportunities and necessary changes for academic institutions to sustain and recruit physician scientists in paediatric/congenital cardiology in the years to come.

Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness

BACKGROUND

One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.

METHODS

In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability.

RESULTS

Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70).

CONCLUSIONS

This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.

Recommendations on Complementary Food Introduction Among Pediatric Practitioners

Importance

The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend waiting 3 to 5 days between the introduction of new complementary foods (solid foods introduced to infants <12 months of age), yet with advances in the understanding of infant food diversity, the guidance that pediatric practitioners are providing to parents is unclear.

Objective

To characterize pediatric practitioner recommendations regarding complementary food introduction and waiting periods between introducing new foods.

Design, Setting, and Participants

In this survey study, a 23-item electronic survey on complementary food introduction among infants was administered to pediatric health care professionals from February 1 to April 30, 2019. Responses were described among the total sample and compared among subgroups. Survey invitations were emailed to 2215 members of the Illinois Chapter of the American Academy of Pediatrics and the national American Academy of Pediatrics' Council on Early Childhood. Participants were required to be primary medical practitioners, such as physicians, resident physicians, or nurse practitioners, providing pediatric care to infants 12 months or younger.

Main Outcomes and Measures

The main outcome measures were recommendations on age of complementary food introduction and waiting periods between the introduction of new foods. Categorical survey items were reported as numbers (percentages) and 95% CIs. Means (SDs) were used to describe continuous survey items.

Results

The survey was sent to 2215 practitioners and completed by 604 (response rate, 27.3%). Of these respondents, 41 were excluded because they did not provide care for infants or pediatric patients. The final analyses included responses from 563 surveys. Of these, 454 pediatricians (80.6%), 85 resident physicians (15.1%), and 20 nurse practitioners (3.6%) completed the survey. Only 217 practitioners (38.6%; 95% CI, 34.1%-44.6%) recommended waiting 3 days or longer between food introduction; 259 practitioners (66.3%; 95% CI, 61.4%-70.8%) recommended waiting that amount of time for infants at risk for food allergy development (P = .02). A total of 264 practitioners (46.9%; 95% CI, 42.8%-51.0%) recommended infant cereal as the first food, and 226 practitioners (40.1%; 95% CI, 36.1%-44.2%) did not recommend a specific order. A total of 268 practitioners (47.6%; 95% CI, 43.5%-51.7%) recommended food introduction at 6 months for exclusively breastfed (EBF) infants, and 193 (34.3%; 95% CI, 30.5%-38.3%) recommended food introduction at 6 months for non-EBF infants (P < .001); 179 practitioners (31.8%; 95% CI, 28.1%-35.8%) recommended food introduction at 4 months for EBF infants, and 239 practitioners (42.5%; 95% CI, 38.4%-46.6%) recommended food introduction at 4 months for non-EBF infants (P < .001). A need for additional training on complementary food introduction was reported by 310 practitioners (55.1%; 95% CI, 50.9%-59.1%).

Conclusions and Relevance

In this survey study, most pediatric practitioners did not counsel families to wait 3 days or longer between introducing foods unless infants were at risk for food allergy development. The findings suggest that the current recommendation limits infant food diversity and may delay early peanut introduction. Because the approach to food allergy prevention has changed, a reevaluation of published feeding guidelines may be necessary.

Children's Palliative Care; the identified Learning Needs of Paediatricians

Aim To determine baseline learning needs of Paediatricians in Ireland when caring for children with palliative care needs. Methods A questionnaire based online survey was conducted. Results One hundred and fourteen paediatricians responded to the survey, the majority were Specialist Registrars but almost half were consultant paediatricians (46% n=52). Most had never had formal education in the paediatric palliative care (57% n=48). Areas of future training that were ranked as important or highly important (percentage of respondents) included: pain management (98% n=81), management of the dying child (96% n=80), palliative care resources (95%n=79), advanced care planning (95% n=79) and communication skills (86% n=71). Those surveyed were asked to comment on the challenges of recent clinical interactions, on analysis three overarching themes emerged; best interests of the child, inadequate training and confidence and co-ordinating care. Conclusion This survey highlights the learning needs of paediatricians and will inform the development of meaningful education sessions for doctors.

E-ASSESS: Creating an EPA Assessment Tool for Structured Simulated Emergency Scenarios

BACKGROUND

The entrustable professional activity (EPA) assessment framework allows supervisors to assign entrustment levels to physician trainees for specific activities. Limited opportunity for direct observation of trainees hampers entrustment decisions, in particular for infrequently performed activities. Simulation allows for direct observation, so tools to assess performance of EPAs in simulation could potentially provide additional data to complement clinical assessments.

OBJECTIVE

We developed and collected validity evidence for a simulation-based tool grounded in the EPA framework.

METHODS

We developed E-ASSESS (EPA Assessment for Structured Simulated Emergency ScenarioS) to assess performance in 2 EPAs among pediatric residents participating in simulation-based team training in 2017-2018. We collected validity data, applying Messick's unitary view. Three raters used E-ASSESS to assign entrustment levels based on performance in simulation. We compared those ratings to entrustment levels assigned by clinical supervisors (different from the study raters) for the same residents on a separate tool designed for clinical practice. We calculated intraclass correlation (ICC) for each tool and Pearson correlation coefficients to compare ratings between tools.

RESULTS

Twenty-eight residents participated in the study. The ICC between the 3 raters for entrustment ratings on E-ASSESS ranged from 0.65 to 0.77, while ICC among raters of the clinical tool were 0.59 and 0.57. We found no significant correlations between E-ASSESS ratings and clinical practice ratings for either EPA (r = -0.35 and 0.38, P > .05).

CONCLUSIONS

Assessment following an EPA framework in the simulation context may be useful to provide data points to inform entrustment decisions as part of resident assessment.

Disseminating Education and Treatment for Children and Adolescents with Eating Disorders Across Levels of Care

BACKGROUND

Eating disorders (EDs) are psychiatric illnesses with high rates of morbidity and mortality. Healthcare providers often receive inadequate training in evidence-based ED assessment and treatment.

DESIGN

Project CORE (Creating Opportunities for Rhode Island Eating Disorders Professionals) was developed to disseminate ED training/education and treatment approaches to the healthcare workforce. An interdisciplinary research team partners with pediatric healthcare professionals/trainees and supports them to better understand how to diagnose, manage, and collaborate across disciplines in the care of patients with EDs.

METHODS

Phase I involves a needs assessment of pediatric healthcare professionals' knowledge, attitudes and needs in treating EDs. Phase II involves the development of training/education approaches, and therapeutic interventions for patients with EDs. In Phase III approaches/interventions are further developed and disseminated across RI.

PRINCIPAL CONCLUSIONS

Project CORE's goals will address barriers to effective ED treatment in RI and broaden the workforce of interdisciplinary providers trained to recognize and treat patients with EDs across multiple healthcare settings.

Foucault on the Wards: Rediscovering Reflection as a Social Pediatrician in Training

The author states that as a second-year medical student with a liberal arts degree, it was often difficult for him to reconcile his former liberal arts education with the current demands of his training. Although the medical curriculum increasingly acknowledges the importance of a biopsychosocial model, the prioritization of knowledge remains the same: know your biological, pharmacological, and anatomical facts. However, the author's experience with a social pediatrics research summer studentship moved him beyond this basic sciences mindset and provided a practical framework for the application of his liberal arts training. The experience was twofold: he worked on a research project while simultaneously shadowing a pediatrician twice a week. His project applied a Foucauldian critical discourse analysis (CDA) to an archive of texts that sought to better characterize the term social pediatrics. The author concludes that the thought-changing reflection, mentorship, and concrete clinical experiences made possible by the summer studentship expanded his worldview.The author discusses the complementary relationship between CDA, clinical experience, and self-reflection in the developing clinician. The purpose of his essay is threefold. First, by drawing on concepts from Descartes' Meditations and Plato's allegory of the cave, he establishes educational continuity between his liberal arts and medical training. Second, using clinical examples, he explores the practicality of discourse analysis and how skills regarding empathy and bias awareness are transferrable to the wards. Last, he highlights the importance of cognitive dissonance and transformative learning in the maturing physician.

Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?

BACKGROUND

Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction.

METHODS

We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements.

RESULTS

There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64).

CONCLUSIONS

Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

If You Build It, Will They Come? A Hard Lesson for Enthusiastic Medical Educators Developing a New Curriculum

BACKGROUND

Primary care forms a critical part of pediatricians' practices, yet the most effective ways to teach primary care during residency are not known.

OBJECTIVE

We established a new primary care curriculum based on Malcolm Knowles' theory of andragogy, with brief clinical content that is easily accessible and available in different formats.

METHODS

We used Kern's model to create a curriculum. In 2013, we implemented weekly e-mails with links to materials on our learning management system, including moderators' curricular content, resident-developed quizzes, and podcasts. After 3 years, we evaluated the curriculum with resident focus groups, retrospective pre-/post-resident surveys, faculty feedback, a review of materials accessed, and resident attendance.

RESULTS

From content analysis of focus groups we learned that residents found the curriculum beneficial, but it was not always possible to do the pre-work. The resident survey, with a response rate of 87% (71 of 82), showed that residents perceived improvement in 37 primary care clinical skills, with differences from 0.64 to 1.46 for scales 1-5 (P < .001 for all). Faculty feedback was positive regarding curriculum organization and structure, but patient care often precluded devoting time to discussing the curriculum. In other ways, our results were disappointing: 51% of residents did not access the curriculum materials, 51% did not open their e-mails, only 37% completed any of the quizzes, and they attended a weekly conference 46% of the time.

CONCLUSIONS

Although residents accessed the curriculum less than expected, their self-assessments reflect perceptions of improvement in their clinical skills after implementation.

Adverse Childhood Experiences and Trauma-Informed Care: An Online Module for Pediatricians

INTRODUCTION

The epidemic of adverse childhood experiences (ACEs) has many known health consequences. Robust research has linked ACEs to increased morbidity and mortality. Because of their frequent interaction with children and their families, pediatricians should be educated to recognize ACEs and practice trauma-informed care (TIC). There is a lack of education for pediatric residents on ACEs despite their significance. Our goals were to identify residents' baseline perceived importance, confidence, and frequency of discussion of ACEs, TIC, toxic stress, and resiliency and evaluate the efficacy of an educational module addressing these topics.

METHODS

A 25-minute self-directed module was created for pediatric residents. The module was accessible online and independently completed by residents during the child advocacy rotation. Pre- and postmodule surveys using a 5-point Likert scale (1 = low, 5 = high) were administered, and median scores of 11 participants who completed both surveys were compared using the Wilcoxon signed rank test.

RESULTS

Presurvey results demonstrated that residents were not confident discussing ACEs, TIC, or resiliency (median = 2). Residents reported that it was very important to discuss ACEs, toxic stress, and resiliency with families (median = 5), although they were rarely discussed in clinic (median = 1 or 2). Matched pre/post data showed significant increases in knowledge, confidence, and discussion frequency.

DISCUSSION

The results demonstrated a need for ACE education for pediatric residents. The matched survey results showed the module's success in knowledge and behavior change. The module can be adapted to other learners to enhance understanding of ACEs.

Care Escalation: Teaching Residents How to Effectively Communicate Patient Care Concerns

INTRODUCTION

Care escalation for patients at risk of deterioration requires that care team members are able to effectively communicate patient care concerns to more senior team members. However, multiple factors inhibit residents from escalating their concerns, which contributes to treatment delays and sentinel events.

METHODS

We developed and implemented an annual 1- and 2-hour escalation curriculum for senior pediatric residents from the University of Colorado. The curriculum consisted of case presentations (one for the 1-hour or two for the 2-hour session), lecture, large-group discussion, and small-group activities. Faculty and fellows facilitated small groups, in which barriers to care escalation and specific tools for effective escalation were discussed. We administered precurriculum surveys for resident self-reflection and postcurriculum surveys for curriculum evaluation.

RESULTS

The curriculum was delivered to 179 residents over 3 years (2016-2018). Surveys were administered during the first 2 years, and 87% of participants completed pre- and postcurriculum surveys. Of all respondents, 88% believed that the curriculum helped them recognize care escalation barriers, and 85% believed that they learned skills for effective escalation. Resident comfort in asking for attending physician help improved from 52% to 95% (p < .001). Analysis of postsurvey open-ended responses indicated that residents valued listening to faculty share their personal experiences of escalating care.

DISCUSSION

The development and implementation of a curriculum to improve resident comfort and perceived ability to escalate patient care concerns are feasible and effective. Further work is needed to evaluate the impact of this curriculum in the clinical setting.

Decision-making dilemmas of paediatricians: a qualitative study in Japan

OBJECTIVE

To delineate the critical decision-making processes that paediatricians apply when treating children with life-threatening conditions and the psychosocial experience of paediatricians involved in such care.

DESIGN

We conducted semistructured, individual face-to-face interviews for each participant from 2014 to 2015. The content of each interview was subjected to a comprehensive qualitative analysis. The categories of dilemma were extracted from a second-round content analysis.

PARTICIPANTS

Participants were board-certified paediatricians with sufficient experience in making decisions in relation to children with severe illnesses or disabilities. We repeated purposive sampling and analyses until we reached saturation of the category data.

RESULTS

We performed interviews with 15 paediatricians. They each reported both unique and overlapping categories of dilemmas that they encountered when making critical decisions. The dilemmas included five types of causal elements: (1) paediatricians' convictions; (2) the quest for the best interests of patients; (3) the quest for medically appropriate plans; (4) confronting parents and families and (5) socioenvironmental issues. Dilemmas occurred and developed as conflicting interactions among these five elements. We further categorised these five elements into three principal domains: the decision-maker (decider); consensus making among families, colleagues and society (process) and the consequential output of the decision (consequence).

CONCLUSIONS

This is the first qualitative study to demonstrate the framework of paediatricians' decision-making processes and the complex structures of dilemmas they face. Our data indicate the necessity of establishing and implementing an effective support system for paediatricians, such as structured professional education and arguments for creating social consensus that assist them to reach the best plan for the management of severely ill children.

Congenital Muscular Torticollis: Bridging the Gap Between Research and Clinical Practice

Congenital muscular torticollis (CMT) is a common postural deformity evident shortly after birth, typically characterized by ipsilateral cervical lateral flexion and contralateral cervical rotation due to unilateral shortening of the sternocleidomastoid muscle. New evidence is emerging on the pathogenesis of CMT, the negative long-term consequences of delaying intervention, and the importance of early identification and early intervention to maximize outcomes. Our purpose in this article is to inform pediatricians and health care providers about new research evidence and share selected recommendations and implementation strategies specifically relevant to pediatric practice to optimize outcomes and health services for infants with CMT.

Cultivating Research Skills During Clinical Training to Promote Pediatric-Scientist Development

Physician-scientists represent a critical component of the biomedical and health research workforce. However, the proportion of physicians who spend a significant amount of effort on scientific research has declined over the past 40 years. This trend has been particularly noticeable in pediatrics despite recent scientific work revealing that early life influences, exposures, and health status play a significant role in lifelong health and disease. To address this problem, the Duke University Department of Pediatrics developed the Duke Pediatric Research Scholars Program for Physician-Scientist Development (DPRS). The DPRS is focused on research training during pediatric residency and fellowship. We aim to provide sufficient research exposure and support to help scholars develop a research niche and scholarly products as well as identify the career pathways that will enable them to achieve their research goals. Herein, we describe the DPRS's organizational structure, core components, recruitment strategies, and initial results, and we discuss implementation challenges and solutions. Additionally, we detail the program's integration with the department's residency and fellowship training programs (with particular reference to the challenges of integrating research into small- to medium-sized residency programs) and describe the development and integration of related initiatives across Duke University School of Medicine. The program served as the basis for 2 successful National Institutes of Health Stimulating Access to Research in Residency (R38) applications, and we hope it will serve as a model to integrate formalized research training for residents and fellows who wish to pursue research careers in academic medicine.

Challenges of training and delivery of pediatric surgical services in developing economies: a perspective from Pakistan

BACKGROUND

As the pediatric population requiring health services rises globally, developing countries are struggling to cater to the growing burden of non-communicable diseases - particularly those requiring specialized surgical care.

MAIN BODY

Despite the literature supporting specialized pediatric surgical care, the developing world is far from meeting the American Pediatric Surgical Association (APSA) Manpower taskforce recommendation of at least 1 qualified pediatric surgeon per 100,000 patients (0-15 years-old). In Pakistan, there is an unmet surgical need in the pediatric population due to a multitude of short shortcomings, notably in quality and quantity of the training programs on offer, and urgent short- and long-term steps are needed to improve this dire situation.

CONCLUSION

It is crucial for the global surgical community to take steps, especially with regards to pediatric surgical training, to ensure delivery of accessible and quality surgical care to the world's children.

A postgraduate curriculum for integrated care: a qualitative exploration of trainee paediatricians and general practitioners' experiences

BACKGROUND

Integrated care unites funding, administrative, organisational, service delivery and clinical levels to create connectivity, alignment and collaboration within and between care delivery and prevention sectors. It aims to improve efficiency by avoiding unnecessary duplication of resources. Consequently, implementing integrated care is increasingly important; however, there are many barriers and how we teach healthcare practitioners to work across systems is under-researched. This paper explores an innovative educational curriculum, the Programme for Integrated Child Health (PICH).

METHODS

The PICH involved an experiential learning approach supported by taught sessions on specific issues relevant to integrated care. A qualitative study was conducted by interviewing 23 participants using semi-structured one-to-one interviews. Participants included trainees (general practice, paediatrics) and programme mentors. Data was thematically analysed.

RESULTS

Results are coded under three main themes: integrated care curriculum components, perceptions of a curriculum addressing integrated care and organisational change, and personal and professional learning. The data highlights the importance of real-world projects, utilising healthcare data, and considering patient perspectives to understand and develop integrated practices. Trainees received guidance from mentors but, more crucially learnt from, with, and about one another. They learnt about the context in which GPs and paediatricians work and developed a deeper understanding through which integrated services could be meaningfully developed.

CONCLUSIONS

This study explored participants' experiences and can be taken forward by educationalists to design curricula to better prepare healthcare practitioners to work collaboratively. The emergence of integrated care brings about challenges for traditional pedagogical approaches as learners have to re-align their discipline-specific approaches with evolving healthcare structures. PICH demonstrated that trainees acquired knowledge through real-word projects and experiential learning; and that this facilitated integration, empowering doctors to become leaders of organisational change. However, there are also many challenges of implementing integrated curricula which need to be addressed, including breaking down professional silos and integrating resourceful healthcare. This study begins to demonstrate the ability of an integrated curriculum to support trainees to work collaboratively, but further work is needed to develop the wider efficacy of the programme incorporating other professional groups, and to assess its longer term impact.

Vaccine health beliefs and educational influences among pediatric residents

OBJECTIVE

A pilot study of pediatric residents to describe perceived benefits and effects of vaccines and educational influences on vaccine practice among pediatric residents.

STUDY DESIGN

Eighty-seven residents, from two institutions in a region with relatively high vaccine hesitancy, responded to a survey conducted in 2014-2015.

RESULTS

Residents identified professional experiences with vaccine preventable diseases (VPDs) and observing pediatricians as most impactful to their vaccine beliefs. Residents who had observed pediatric faculty agreeing to alternative or delayed vaccinations were more likely to believe this to be acceptable vaccine practice (70.1% vs. 21.1%, χ² = 17.778, p < 0.001). Most residents (68 [79.1%]) reported feeling confident in their ability to discuss vaccines.

CONCLUSIONS

Pediatricians must be equipped with accurate vaccine health beliefs to impact parental vaccine hesitancy. This study identifies important gaps in medical education, with pediatric residents reporting limitations in their professional experience with VPDs and high rates of observing alternative vaccination practice.

The Provision of HIV Post-Exposure Prophylaxis in the Context of Child Sex Trafficking

Child sex trafficking (CST) victims are at risk for HIV infection due to a convergence of both social and biological factors. However, sparse recommendations and guidelines exist for providers on the provision of HIV non-occupational post-exposure prophylaxis (nPEP) for CST patients. We evaluated whether pediatricians would provide HIV nPEP in a clinical vignette where a patient disclosed ongoing involvement in CST. Participants were relatively divided regarding whether they would provide HIV nPEP; 58.8% responded yes and 41.2% responded no. This highlights the need for medical guidelines to address the complex and case specific considerations of providing nPEP to these victims.

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2-5) to 6 (IQR 4-7) following SST (p < 0.0009, median difference 2, 95% CI 1-3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

Retention of knowledge and skills in pediatric basic life support amongst pediatricians

Retention of resuscitation skills is usually assessed at a predefined moment, which enables participants to prepare themselves, possibly introducing bias. In this multicenter study, we evaluated the retention of knowledge and skills in pediatric basic life support (PBLS) amongst 58 pediatricians and pediatric residents with an unannounced examination. Practical PBLS skills were assessed with a validated scoring instrument, theoretical knowledge with a 10-item multiple-choice test (MCQ). Participants self-assessed their PBLS capabilities using five-point Likert scales. Background data were collected with a questionnaire. Of our participants, 21% passed the practical PBLS exam: 29% failed on compressions/ventilations, 31% on other parts of the algorithm, 19% on both. Sixty-nine percent passed the theoretical test. Participants who more recently completed a PBLS course performed significantly better on the MCQ (p = 0.03). This association was less clear-cut for performance on the practical exam (p = 0.11). Older, attending pediatricians with more years of experience in pediatrics performed less well than their younger colleagues (p < 0.05). Fifty-one percent of the participants considered themselves competent in PBLS. No correlation was found between self-assessed PBLS capabilities and actual performance on the practical exam (p = 0.25).

CONCLUSION

Retention of PBLS skills appears to be poor amongst pediatricians and residents, whereas PBLS knowledge is retained somewhat better. What is Known: • Pediatricians and pediatric residents are not always competent in pediatric basic life support (PBLS) in daily practice. Poor retention of skills supposedly accounts for this incompetence. Without regular exposure, resuscitation skills usually deteriorate within 3 to 6 months after training. • Examination of resuscitation skills usually takes place after training. Also, in most studies evaluating retention of skills, participants are tested at a predefined moment. Inasmuch as participants are able to prepare themselves, these assessments do not reflect the ad hoc resuscitation capabilities of pediatricians and residents. What is New: • In this study, pediatricians and pediatric residents had to complete an unannounced PBLS exam at variable time intervals from last certification. Retention of PBLS skills was rather poor (pass rate 21%). • The PBLS skills of older, attending pediatricians with many working years in pediatrics appeared to be inferior to those of their younger colleagues.

Child Neurology Recruitment and Training: Views of Residents and Child Neurologists From the 2015 AAP/CNS Workforce Survey

BACKGROUND

To assess and compare resident and practicing child neurologists' attitudes regarding recruitment and residency training in child neurology.

METHODS

A joint task force of the American Academy of Pediatrics and the Child Neurology Society conducted an electronic survey of child neurology residents (n = 305), practicing child neurologists (n = 1290), and neurodevelopmental disabilities specialists (n = 30) in 2015. Descriptive and multivariate analyses were performed.

RESULTS

Response rates were 32% for residents (n = 97; 36% male; 65% Caucasian) and 40% for practitioners (n = 523; 63% male; 80% Caucasian; 30% lifetime certification). Regarding recruitment, 70% (n = 372) attributed difficulties recruiting medical students to insufficient early exposure. Although 68% (n = 364) reported that their medical school required a neurology clerkship, just 28% (n = 152) reported a child neurology component. Regarding residency curriculum, respondents supported increased training emphasis for genetics, neurodevelopmental disabilities, and multiple other subspecialty areas. Major changes in board certification requirements were supported, with 73% (n = 363) favoring reduced adult neurology training (strongest predictors: fewer years since medical school P = 0.003; and among practicing child neurologists, working more half-day clinics per week P = 0.005). Furthermore, 58% (n = 289) favored an option to reduce total training to 4 years, with 1 year of general pediatrics. Eighty-two percent (n = 448) would definitely or probably choose child neurology again.

CONCLUSIONS

These findings provide support for recruitment efforts emphasizing early exposure of medical students to child neurology. Increased subspecialty exposure and an option for major changes in board certification requirements are favored by a significant number of respondents.

Long-term pediatrician outcomes of a parent led curriculum in developmental disabilities

Previous research has demonstrated high satisfaction and perceived relevance of Project DOCC (Delivery of Chronic Care), a parent led curriculum in developmental disabilities, across a sample of medical residents.

AIMS

The influence of such a training program on the clinical practices and professional activities of these residents once they are established in their careers as physicians, however, has not been studied; this was the aim of the present study.

METHODS

An anonymous follow-up survey was designed and disseminated to physicians who participated in Project DOCC during their one-month developmental disabilities rotation as part of their pediatrics or medicine/pediatric residency between 2002 and 2010. Fifty-eight physicians completed the survey.

RESULTS

The findings suggest that participation in a parent led curriculum during medical residency had a lasting impact on physicians' relationships with families. Specifically, a majority of the physicians espoused a family-centered approach to care, a sensitivity to the interactional effect that caring for a Child with Special Health Care Needs (CSHCN) has on family members, the need for physicians to have a prominent role in community resource coordination, and the importance of an integrated approach to health care provision.

CONCLUSIONS

Use of a parent led curriculum as a means to increase the provision of family-centered care by physicians is supported.

Sex Trafficking Assessment and Resources (STAR) for Pediatric Attendings in Rhode Island

BACKGROUND

Domestic minor sex trafficking (DMST) victims have unique medical and mental health needs and present frequently for medical attention. Little is known about the reported training, screening, comfort and knowledge of DMST among pediatricians in Rhode Island who likely encounter these patient victims without knowing.

METHODS

An anonymous electronic survey sent to Rhode Island Hospital staff physicians from November 2014 through January 2015.

RESULTS

Of the 109 participants, the majority reported no training, screened no patients for DMST in the past year, did not know any resources available and had limited knowledge and comfort with this pediatric patient population.

CONCLUSIONS

Rhode Island pediatricians of various specialties do not feel adequately prepared to identify and respond to a DMST patient population. These findings inform the need for increased training and education on DMST in our medical community. [Full article available at http://rimed.org/rimedicaljournal-2016-09.asp, free with no login].

Can family pediatricians in Italy identify child abuse? A survey

The introduction of the concept of child abuse has radically changed the mode of interaction between pediatricians and children, but also the practice of sanitary personnel in primary care centers, who are often the first to see victims of maltreatment. This study aims at illustrating the results of a questionnaire sent to family doctors, pediatricians and hospitals in Milan and surrounding areas concerning child abuse. Among all the operators, 273 returned the questionnaires. The results show scarce knowledge on how to report to judicial authority in cases of child abuse (51.5%), mainly because of lack of basilar information concerning the manner of reporting. For what concerns specific training, almost half the subjects recruited for the study admitted not to have attended any congress or meeting concerning child maltreatment in the last three years. In the same time span, more than one third has not read any scientific articles concerning child abuse. In addition, 75.6% admit to not ever having attended any professional training course concerning child maltreatment. This study highlights the scarce knowledge on the behalf of pediatricians and general practitioners regarding how to deal with child abuse and the importance of proper training programs.

A survey of mindset theories of intelligence and medical error self-reporting among pediatric housestaff and faculty

BACKGROUND

Intelligence theory research has illustrated that people hold either "fixed" (intelligence is immutable) or "growth" (intelligence can be improved) mindsets and that these views may affect how people learn throughout their lifetime. Little is known about the mindsets of physicians, and how mindset may affect their lifetime learning and integration of feedback. Our objective was to determine if pediatric physicians are of the "fixed" or "growth" mindset and whether individual mindset affects perception of medical error reporting. 

METHODS

We sent an anonymous electronic survey to pediatric residents and attending pediatricians at a tertiary care pediatric hospital. Respondents completed the "Theories of Intelligence Inventory" which classifies individuals on a 6-point scale ranging from 1 (Fixed Mindset) to 6 (Growth Mindset). Subsequent questions collected data on respondents' recall of medical errors by self or others.

RESULTS

We received 176/349 responses (50 %). Participants were equally distributed between mindsets with 84 (49 %) classified as "fixed" and 86 (51 %) as "growth". Residents, fellows and attendings did not differ in terms of mindset. Mindset did not correlate with the small number of reported medical errors.

CONCLUSIONS

There is no dominant theory of intelligence (mindset) amongst pediatric physicians. The distribution is similar to that seen in the general population. Mindset did not correlate with error reports.