Aditee P. Narayan

Pediatric Residency Training in Child Abuse and Neglect in the United States

BACKGROUND. Child abuse and neglect are leading public health problems with significant morbidity and mortality. Previous studies indicate that physicians often lack knowledge and confidence in addressing child abuse and neglect. OBJECTIVES. Our goal was to assess the child abuse and neglect curricula in pediatric residency programs as reported by chief residents and to identify levels of preparedness of residents to address child abuse and neglect on graduation. We analyzed variables related to preparedness. METHODS. A 28-item survey was sent to chief residents of all 203 Accreditation Council for Graduate Medical Education–accredited pediatric residency programs in the United States from 2004–2005. We performed descriptive, bivariable, and multivariable analyses. RESULTS. The response rate was 71%. Most programs taught didactics on physical and sexual abuse, but only 54% included domestic violence. Ninety-three percent of respondents rated their didactics as useful or very useful. Forty-one percent of programs required mandatory clinical rotations in child abuse and neglect, 57% offered elective rotations, and 25% offered no rotations at all. Respondents rated the levels of preparedness of graduating residents to address child abuse and neglect as: very well (12%), well (54%), somewhat well (28%), or not well (6%). Preparedness was significantly associated with didactic usefulness, number of hours of didactics, total number of inpatient cases of child abuse and neglect seen, percent of residents completing mandatory rotations, number of sexual abuse cases during mandatory rotation, number of physical abuse cases during mandatory rotation, and length of mandatory rotation. CONCLUSIONS. Mandatory clinical experiences in child abuse and neglect improve the preparedness of graduating residents to identify and evaluate patients for child abuse and neglect. Perhaps residency training in child abuse and neglect should be a required subspecialty rotation with more explicit curricular content than in the current mandates.

Do pediatric residents prefer interactive learning? Educational challenges in the duty hours era

Background: The volume of information that physicians must learn is increasing; yet, trainee educational time is limited. Many experts propose using trainees’ learning preferences to guide teaching. However, data regarding predominant learning preferences within pediatrics are limited. Aim: Identify predominant learning preferences among pediatric residents in a Residency Training Program. Methods: The Visual–Aural–Read/Write–Kinesthetic (VARK) questionnaire and Kolb Learning Style Inventory (LSI) were administered anonymously to 50 pediatric residents. Results: Learning style assessments were completed by 50 pediatric residents. Residents were significantly more likely to be accommodating on the Kolb LSI, which is consistent with an interactive learning preference (p < 0.01); 30% demonstrated a multimodal preference on the Kolb LSI (Figure 1). VARK assessments demonstrated that 45 (90%) respondents were kinesthetic, which is also consistent with a significant preference for interactive learning (p < 0.01). Forty (80%) were found to be multimodal on the VARK (Figure 1). There was no association between learning preference and the residents’ anticipated career choice or level of training. Conclusions: The predominant learning preferences among a cohort of pediatric residents from a single training program were consistent with a preference for interactive learning, suggesting that some trainees may benefit from supplementation of educational curricula with additional interactive experiences. Continued investigation is needed in this area to assess the effectiveness of adapting teaching techniques to individual learning preferences.

Milestone-Based Assessments Are Superior to Likert-Type Assessments in Illustrating Trainee Progression

BACKGROUND The Pediatrics Milestone Project uses behavioral anchors, narrative descriptions of observable behaviors, to describe learner progression through the Accreditation Council for Graduate Medical Education competencies. Starting June 2014, pediatrics programs were required to submit milestone reports for their trainees semiannually. Likert-type scale assessment tools were not designed to inform milestone reporting, creating a challenge for Clinical Competency Committees. OBJECTIVE To determine if milestone-based assessments better stratify trainees by training level compared to Likert-type assessments. METHODS We compared assessment results for 3 subcompetencies after changing from a 5-point Likert scale to milestone-based behavioral anchors in July 2013. Program leadership evaluated the new system by (1) comparing PGY-1 mean scores on Likert-type versus milestone-based assessments; and (2) comparing mean scores on the Likert-type versus milestone-based assessments across PGY levels. RESULTS Mean scores for PGY-1 residents were significantly higher on the prior years Likert-type assessments than milestone-based assessments for all 3 subcompetencies (P < .01). Stratification by PGY level was not observed with Likert-type assessments (eg, interpersonal and communication skills 1 [ICS1] mean score for PGY-1, 3.99 versus PGY-3, 3.98; P  =  .98). In contrast, milestone-based assessments demonstrated stratification by PGY level (eg, the ICS1 mean score was 3.06 for PGY-1, 3.83 for PGY-2, and 3.99 for PGY-3; P < .01 for PGY-1 versus PGY-3). Significantly different means by trainee level were noted across 21 subcompetencies on milestone-based assessments (P < .01 for PGY-1 versus PGY-3). CONCLUSIONS Initial results indicate milestone-based assessments stratify trainee performance by level better than Likert-type assessments. Average PGY-level scores from milestone-based assessments may ultimately provide guidance for determining whether trainees are progressing at the expected pace.

Facilitated Peer Group Mentoring: A Case Study of Creating Leadership Skills Among the Associate Program Directors of the APPD

I t is well recognized that academic faculty benefit from mentoring relationships in order to achieve their professional goals, facilitate their scholarly productivity, and make meaningful contributions to their colleagues, trainees, institutions, and departments. Junior faculty are faced with many challenges in developing effective mentoring relationships, including lack of available senior faculty members with proper skill sets or interest in mentorship. Although many mentoring models exist, the most commonly pursued by academic faculty is dyadic mentoring. In traditional dyadic mentoring, one mentor is matched with one mentee (often geographically) based on common interests. Ideally, the dyad participates in a bidirectional relationship. There is a growing body of evidence that other innovative mentoring models, such as facilitated peer group mentoring (FPGM), may be more successful. In FPGM, a senior mentor is assigned to a small group of mentees. The group members serve as peer mentors to each other while working on common interests or projects. The process is facilitated by the senior mentor, who may or may not be a content expert. In this paper, we discuss a case study in which effective, productive mentoring was provided through the use of FPGM. This case study involving associate program directors is illustrative of a successful mentoring experience that resulted in academic productivity and enhanced leadership skills. Associate program directors are involved directly in the

An Innovative Process for Faculty Development in Residency Training

Background: For programs to accomplish the goals of the Accreditation Council of Graduate Medical Education (ACGME) Outcome Project, faculty must be trained to deliver and assess education that is level-specific, competency-based, standardized, integrated, and easily accessible. Description: An innovative faculty development model that accomplishes these goals is described. This model trained faculty to analyze curricular needs and then to design, disseminate, and evaluate their curricula. This model utilized guided experiential learning that promoted the creation of residency program curricula and faculty buy-in. Evaluation: Key outcomes included high levels of resident satisfaction and use of the curricula, improved tracking of rotation progress, improved faculty satisfaction with their role as educators, perceived improvement in resident evaluations, and increased involvement of faculty in creating and teaching to the curriculum. Conclusion: This process may be adapted by other programs based on their available resources to address faculty development needs. The process serves as a model for meeting ACGME requirements.

Can Tablet Computers Enhance Faculty Teaching

BACKGROUND Learner benefits of tablet computer use have been demonstrated, yet there is little evidence regarding faculty tablet use for teaching. OBJECTIVE Our study sought to determine if supplying faculty with tablet computers and peer mentoring provided benefits to learners and faculty beyond that of non-tablet-based teaching modalities. METHODS We provided faculty with tablet computers and three 2-hour peer-mentoring workshops on tablet-based teaching. Faculty used tablets to teach, in addition to their current, non-tablet-based methods. Presurveys, postsurveys, and monthly faculty surveys assessed feasibility, utilization, and comparisons to current modalities. Learner surveys assessed perceived effectiveness and comparisons to current modalities. All feedback received from open-ended questions was reviewed by the authors and organized into categories. RESULTS Of 15 eligible faculty, 14 participated. Each participant attended at least 2 of the 3 workshops, with 10 to 12 participants at each workshop. All participants found the workshops useful, and reported that the new tablet-based teaching modality added value beyond that of current teaching methods. Respondents developed the following tablet-based outputs: presentations, photo galleries, evaluation tools, and online modules. Of the outputs, 60% were used in the ambulatory clinics, 33% in intensive care unit bedside teaching rounds, and 7% in inpatient medical unit bedside teaching rounds. Learners reported that common benefits of tablet computers were: improved access/convenience (41%), improved interactive learning (38%), and improved bedside teaching and patient care (13%). A common barrier faculty identified was inconsistent wireless access (14%), while no barriers were identified by the majority of learners. CONCLUSIONS Providing faculty with tablet computers and having peer-mentoring workshops to discuss their use was feasible and added value.

Using an Innovative Curriculum Evaluation Tool to Inform Program Improvement: The Clinical Skills Fair

BACKGROUND Program evaluation is important for assessing the effectiveness of the residency curriculum. Limited resources are available, however, and curriculum evaluation processes must be sustainable and well integrated into program improvement efforts. INTERVENTION We describe the pediatric Clinical Skills Fair, an innovative method for evaluating the effectiveness of residency curriculum through assessment of trainees in 2 domains: medical knowledge/patient care and procedure. Each year from 2008 to 2011, interns completed the Clinical Skills Fair as rising interns in postgraduate year (PGY)-1 (R1s) and again at the end of the year, as rising residents in PGY-2 (R2s). Trainees completed the Clinical Skills Fair at the beginning and end of the intern year for each cohort to assess how well the curriculum prepared them to meet the intern goals and objectives. RESULTS Participants were 48 R1s and 47 R2s. In the medical knowledge/patient care domain, intern scores improved from 48% to 65% correct (P < .001). Significant improvement was demonstrated in the following subdomains: jaundice (41% to 65% correct; P < .001), fever (67% to 94% correct; P < .001), and asthma (43% to 62% correct; P  =  .002). No significant change was noted within the arrhythmia subdomain. There was significant improvement in the procedure domain for all interns (χ(2)  =  32.82, P < .001). CONCLUSIONS The Clinical Skills Fair is a readily implemented and sustainable method for our residency program curriculum assessment. Its feasibility may allow other programs to assess their curriculum and track the impact of programmatic changes; it may be particularly useful for program evaluation committees.

Strengthening the associate program director workforce: needs assessment and recommendations.

From the Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Narayan); Department of Pediatrics, University of Washington, Seattle,Wash (DrMcPhillips); Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo (Dr Anderson); Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga (Dr Gardner); Department of Pediatrics, University of Vermont, Burlington, Vt (Dr Larrabee); Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio (Dr Poynter); Department of Pediatrics, University of Missouri—Kansas City School of Medicine and Children’s Mercy Hospitals and Clinics, Kansas City, Mo (Dr Mann); and Department of Pediatrics Drexel University College of Medicine, Section of General Pediatrics St. Christopher’s Hospital for Children, Philadelphia, Pa (Dr Spector) The authors declare that they have no conflict of interest. Address correspondence to Aditee P. Narayan, MD, MPH, Duke University Medical Center, Pediatrics, DUMCBox 3127, Durham, NC 27710 (e-mail: aditee.narayan@duke.edu). Received for publication May 12, 2014; accepted May 12, 2014.

View From the Association of Pediatric Program DirectorsStrengthening the Associate Program Director Workforce: Needs Assessment and Recommendations

From the Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Narayan); Department of Pediatrics, University of Washington, Seattle,Wash (DrMcPhillips); Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo (Dr Anderson); Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga (Dr Gardner); Department of Pediatrics, University of Vermont, Burlington, Vt (Dr Larrabee); Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio (Dr Poynter); Department of Pediatrics, University of Missouri—Kansas City School of Medicine and Children’s Mercy Hospitals and Clinics, Kansas City, Mo (Dr Mann); and Department of Pediatrics Drexel University College of Medicine, Section of General Pediatrics St. Christopher’s Hospital for Children, Philadelphia, Pa (Dr Spector) The authors declare that they have no conflict of interest. Address correspondence to Aditee P. Narayan, MD, MPH, Duke University Medical Center, Pediatrics, DUMCBox 3127, Durham, NC 27710 (e-mail: aditee.narayan@duke.edu). Received for publication May 12, 2014; accepted May 12, 2014.

Integration of the Nurse Practitioner Into Your Child Abuse Team

Child maltreatment is a leading cause of childhood morbidity in the United States, often leading to lifelong adverse health consequences. Currently, there is a nationwide shortage of child abuse pediatricians (CAPs), resulting in many unfilled child abuse positions throughout the United States. In addition, the number of future CAPs currently in fellowship training will meet neither the current need for CAPs nor provide replacements for the senior CAPs who will be retiring in the next 5 to 10 years. Although it is recognized that pediatric nurse practitioners (PNPs) play an important role in the care of maltreated children, there are few available data on the impact of the PNP as an integral member of the child abuse team. Using the outcomes logic model, we present a systematic process through which the PNP can be effectively integrated into a medical child abuse team. The outcomes from this process show that the addition of PNPs to the child abuse team not only provides immediate relief to the nationwide CAP shortage but also significantly augments the diverse clinical skills and expertise available to the child abuse team.