Catherine Michelson

Location, Location, Location: Teaching About Neighborhoods in Pediatrics

From the Division of General and Community Pediatrics (Drs Real, Beck, and Klein), Division of Hospital Medicine (Drs Beck and Klein), Cincinnati Children’s Hospital Medical Center, Ohio; and Division of General Pediatrics, Boston Medical Center (Dr Michelson), Mass The authors have no conflicts of interest to disclose. Address correspondence to Francis J. Real, MD, 3333 Burnet Ave, MLC 2011, Cincinnati, OH 45229 (e-mail: francis.real@cchmc.org).

Keystone: Exploring Pediatric Residents’ Experiences in a Longitudinal Integrated Block

Abstract Problem: Residency training in many specialties has traditionally been divided into short, discrete, single-specialty rotations. Although providing the learner with in-depth exposure to a specific discipline, educators have challenged this rotational model, citing problems with patient and team continuity and maladaptive coping. Longitudinal integrated clerkships, adopted by many medical schools, offer an alternative model and have demonstrated improved outcomes for students related to patient-centeredness, advocacy, and integration with teams. Despite this, longitudinal integrated training in residency is rare. Intervention: We developed a novel 3-month longitudinal integrated block for residents, called Keystone. The block combined 3 previously discrete, shorter rotations in developmental-behavioral pediatrics, advocacy, and emergency medicine into a longer and integrated experience. Within each week, the block utilized half-day sessions in the resident’s primary care clinic, a new continuity Developmental Behavioral Pediatrics clinic where the resident worked with the same faculty preceptor and interprofessional team each week, shifts in the emergency department, and half-day sessions dedicated to clinic- and community-based advocacy activities. Context: The context was a single, large pediatric urban residency program based at 2 university-affiliated hospitals, an academic freestanding children’s hospital, and academic safety net hospital. Outcome: Using a phenomenologic framework, we conducted interviews and a focus group discussion to explore residents’ attitudes about the block; their perceptions regarding the block’s impact on relationships with preceptors, peers, or patients; and the block’s impact on learning and practice. Fourteen residents participated, 10 in interviews and 4 in the focus group discussion. Six themes emerged from thematic analysis: (a) the longitudinal nature of Keystone influenced professional relationships and as a result entrustment, (b) the longitudinal integrated design shaped engagement and learning, (c) flexibility promoted work–life balance and self-directed learning, (d) learners experienced time and space for professional identity development, (e) Keystone provided a unique opportunity to reclaim patient-centeredness, and (f) learners experienced important advantages and challenges related to the schedule. Lessons Learned: The longitudinal integrated nature of Keystone provided a novel structure for addressing important yet challenging educational goals in residency, including enhancing relationships, facilitating entrustment and engagement, encouraging patient-centeredness, and emphasizing the importance of self-directed learning.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns

Abstract Background: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. Methods: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. Results: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. Conclusions: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Milestone Ratings and Supervisory Role Categorizations Swim Together, but is the Water Muddy?

OBJECTIVE This single-specialty, multi-institutional study aimed to determine 1) the association between milestone ratings for individual competencies and average milestone ratings (AMRs) and 2) the association between AMRs and recommended supervisory role categorizations made by individual clinical competency committee (CCC) members. METHODS During the 2015-16 academic year, CCC members at 14 pediatric residencies reported milestone ratings for 21 competencies and recommended supervisory role categories (may not supervise, may supervise in some settings, may supervise in all settings) for residents they reviewed. An exploratory factor analysis of competencies was conducted. The associations among individual competencies, the AMR, and supervisory role categorizations were determined by computing bivariate correlations. The relationship between AMRs and recommended supervisory role categorizations was examined using an ordinal mixed logistic regression model. RESULTS Of the 155 CCC members, 68 completed both milestone assignments and supervision categorizations for 451 residents. Factor analysis of individual competencies controlling for clustering of residents in raters and sites resulted in a single-factor solution (cumulative variance: 0.75). All individual competencies had large positive correlations with the AMR (correlation coefficient: 0.84-0.93), except for two professionalism competencies (Prof1: 0.63 and Prof4: 0.65). When combined across training year and time points, the AMR and supervisory role categorization had a moderately positive correlation (0.56). CONCLUSIONS This exploratory study identified a modest correlation between average milestone ratings and supervisory role categorization. Convergence of competencies on a single factor deserves further exploration, with possible rater effects warranting attention.

Lessons From the 2013 Boston Marathon: Incorporating Residents Into Institutional Emergency Plans

* Abbreviations: BCH — : Boston Children’s Hospital BMC — : Boston Medical Center EPP — : emergency preparedness plan When 2 pressure-cooker bombs exploded during the 2013 Boston Marathon, first responders and hospitals across the city coordinated a swift and effective response, caring for 264 patients across 26 local hospitals.1 Residents from the Boston Combined Residency Program were staffing 3 of these hospitals, whereas others were watching or running the marathon. Shortly after the bombings, overwhelmed by call volumes, cellular service went down across Boston. Our program was challenged by hampered communication with residents. Beyond difficulties with communication, the residents’ role in the disaster response was unclear. Well-intentioned residents wanted to help out, but didn’t know how, which added a layer of confusion that is common in disaster scenarios. Would residents be expected to provide surge staffing, and who would make that determination? Would all residents participate or just the most experienced? Later in the week, a citywide manhunt led to “shelter in place” orders, with all civilians mandated to remain inside while law enforcement worked to locate the bombing suspects. With this development, a new set of questions arose. What was the best way to find a balance between patient safety and residents’ personal safety? Could trainees be asked to work beyond scheduled shifts? Should trainees be asked to commute to work during … Address correspondence to Katherine R. Schlosser, MD, Division of Critical Care Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: katherine.schlosser{at}childrens.harvard.edu

Development and Pilot Implementation of a Trauma-Informed Care Curriculum for Pediatric Residents

From the Department of Pediatrics (Drs Schiff, Zuckerman, Hutton, Michelson, and Bair-Merritt), Department of Nursing (Ms Genatossio), BostonMedical Center, and BostonUniversity School of Medicine (Drs Schiff, Zuckerman, Hutton,Michelson, and Bair-Merritt), Boston,Mass The authors have no conflicts of interest to disclose. Address correspondence to Davida M. Schiff, MD, Department of Pediatrics, Boston Medical Center, 88 E Newton, Boston, MA 02118 (e-mail: Davida.Schiff@bmc.org). Received for publication November 7, 2016; accepted March 16, 2017.