Christy L. Cummings

Who is performing medical procedures in the neonatal intensive care unit

Objective:Owing to resident work-hour reductions and more permanent personnel in the newborn intensive care unit (NICU), we sought to determine if pediatric housestaff are missing learning opportunities in procedural training due to non-participation.Study Design:A prospective, observational study was conducted at an academic NICU using self-reported data from neonatal personnel after attempting 188 procedures on 109 neonates, and analyzed using Fishers exact and χ 2-tests.Result:Housestaff first attempted 32% of procedures (P<0.001) and were less likely to make attempts early in the academic year (P<0.001). There was no significant difference in attempts based on urgency of situation (P=0.742). Of procedures performed by non-housestaff personnel, 93% were completed while housestaff were present elsewhere in the unit.Conclusion:Pediatric housestaff performed the minority of procedures in the NICU, even in non-urgent situations, and were often uninvolved in other procedures, representing missed learning opportunities.

Ethics of emerging technologies and their transition to accepted practice: intestinal transplant for short bowel syndrome

Parental counseling becomes complex when considering the use of emerging technologies, especially if it is unclear whether the level of evidence is sufficient to transform the proposed therapy into accepted practice. This paper addresses ethical issues underlying medical decision-making and counseling in the setting of emerging treatments, when long-term outcomes are still in the process of being fully validated. We argue that the ethical transition of emerging technologies, ideally from ethically impermissible to permissible, to obligatory, depends primarily on two factors: outcome data (or prognosis) and treatment feasibility. To illustrate these points, we will use intestinal transplant for short bowel syndrome (SBS) as a specific example. After reviewing the data, this paper will identify the ethical justifications for both comfort care only and intestinal transplant in patients with ultra SBS, and argue that both are ethically permissible, but neither is obligatory. The approach outlined will not only be valuable as ultra SBS outcomes data continue to change, but will also be applicable to other novel therapies as they emerge in perinatal medicine.

Counselling variation among physicians regarding intestinal transplant for short bowel syndrome

Background Intestinal transplant in infants with severe short bowel syndrome (SBS) is an emerging therapy, yet without sufficient long-term data or established guidelines, resulting in possible variation in practice. Objectives To assess current attitudes and counselling practices among physicians regarding intestinal transplant in infants with SBS, and to determine whether counselling and management vary between subspecialists or centres. Methods A national sample of practicing paediatric surgeons and neonatologists was surveyed via the American Academy of Paediatrics listserves. Results were analysed by physician subspecialty and again by presence or absence of intestinal transplant at respondents centre. Results The survey was completed by 433 respondents, consisting of 363 neonatologists and 70 paediatric surgeons. Fifty-seven respondents (13.2%) practiced at a centre that performed intestinal transplants in children. The vast majority of respondents (91% for preterm, 95% for term neonates) felt that maintaining a neonate with SBS on total parenteral nutrition for intestinal transplant was ethically optional (neither impermissible nor obligatory), and that parents should be given an informed choice whether to pursue that option. However, only 33% indicated they often/always offer intestinal transplant as a treatment option to families in this situation. Conclusions There is a marked disparity between individual physicians’ beliefs regarding the acceptability of intestinal transplant for severe SBS and their reported practice. Wide variability exists among physicians with respect to their knowledge, beliefs and practice regarding severe SBS, raising concerns about transparency and justice. Survival data prior to transplant, currently unavailable, are essential to rational decision making and informed parental permission.

Communication in the Era of COWs: Technology and the Physician–Patient–Parent Relationship

* Abbreviations: COW — : computer on wheels How did I find myself leading family-centered rounds a while ago in the NICU, yet unable to actually see any of my team members, not to mention my patient’s parents sitting just several feet away? I looked up while listening to a summary of the infant’s overnight events, and suddenly it hit me, something was amiss. My entire team was hidden, our views obstructed, from each other and the patient’s family. No one was fully focused or making eye contact during the presentation. I could not see to whom the presenting voice belonged. One resident was fixated on the computer screen, while another was obliviously typing away, nose to keyboard. This hardly looked the picture of family-centered rounding, or the epitome of good communication, things I strived for. The humbling culprit, aside from me? COWs. No, not the grass-eating, milk-producing kind of cow, but rather the portable data-crunching COW, affectionately short for “computer on wheels.” These mobile computing machines have now become permanent features of many hospitals and clinics, and for good reason. COWs help streamline and improve medical care, including electronic patient charting and documentation, increasingly onerous tasks. They allow physicians to, for example, quickly check on a laboratory result or write an admission note, while watching over a critical patient. COWs also help expedite clinic notes during back-to-back patient encounters. The COW certainly facilitates on-the-go charting, the new fast food of medical documentation for the multitasking physician. But, as I struggled with my … Address for correspondence to Christy L. Cummings, MD, Division of Newborn Medicine, Boston Children’s Hospital, 300 Longwood Ave, Hunnewell 437, Boston, MA 02115. E-mail: christy.cummings{at}childrens.harvard.edu

Ethics and professionalism education during neonatal–perinatal fellowship training in the United States

Objective:The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal–perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues.Study Design:Neonatal–Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas.Result:Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is ‘important/very important’. Only 63% of Directors and 37% of fellows/graduates rated ethics education as ‘excellent/very good’ (P=0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P<0.001). Teaching methods and their perceived effectiveness varied widely.Conclusion:Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency.

Teaching and assessing ethics in the newborn ICU

Ethics and professionalism education has become increasingly recognized as important and incorporated into graduate medical education. However, such education has remained largely unstructured and understudied in neonatology. Neonatal-perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills, and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies. This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency. The need for consensus and future research in these domains is also highlighted.

Should Neonatologists Give Opinions Withdrawing Life-sustaining Treatment?

An infant has a massive intracranial hemorrhage. She is neurologically devastated and ventilator-dependent. The prognosis for pulmonary or neurologic recovery is bleak. The physicians and parents face a choice: withdraw the ventilator and allow her to die or perform a tracheotomy? The parents cling to hope for recovery. The physician must decide how blunt to be in communicating his own opinions and recommendations. Should the physician try to give just the facts? Or should he also make a recommendation based on his own values? In this article, experts in neonatology, decision-making, and bioethics discuss this situation and the choice that the physician faces.

Practices and education surrounding anticipated periviable deliveries among neonatal-perinatal medicine and maternal-fetal medicine fellowship programs

Objectives:To explore national practices of periviable decision-making and care, and to determine and compare trainee education in this domain, within neonatal-perinatal medicine (NPP) and maternal-fetal medicine (MFMP) fellowship programs.Study Design:A 75-item survey was sent to NPP and MFMP program directors in the United States.Results:In all, 79 of 168 surveys were completed (47%). MFMPs reported offering active interventions for bigger or more mature fetuses (versus NPPs). Variability exists in estimated frequency of simultaneous antenatal counseling by both specialties (range 0 to 90%) and of inter-specialty communication before consultation (range 5 to 100%). One-quarter of MFMPs reported no fellow education regarding periviable deliveries, versus 2% of NPPs (P=0.002); 40% of MFMPs teach fellows about periviable ethics, versus 63% of NPPs (P=0.05). NPPs more frequently utilize role modeling (P=0.01) and simulation (P=0.01) as learning methods.Conclusion:NPPs and MFMPs report different, often asynchronous, practices and fellow education regarding antenatal counseling and resuscitation at periviability.

When worlds intersect: practical and ethical challenges when caring for international patients in the NICU

When worlds intersect: practical and ethical challenges when caring for international patients in the NICU

Assessing Ethics Knowledge: Development of a Test of Ethics Knowledge in Neonatology

Objective To develop and validate the Test of Ethics Knowledge in Neonatology (TEK‐Neo) with good internal consistency reliability, item performance, and construct validity that reliably assesses interprofessional staff and trainee knowledge of neonatal ethics. Study design We adapted a published test of ethics knowledge for use in neonatology. The novel instrument had 46 true/false questions distributed among 7 domains of neonatal ethics: ethical principles, professionalism, genetic testing, beginning of life/viability, end of life, informed permission/decision making, and research ethics. Content and correct answers were derived from published statements and guidelines. We administered the voluntary, anonymous test via e‐mailed link to 103 participants, including medical students, neonatology fellows, neonatologists, neonatology nurses, and pediatric ethicists. After item reduction, we examined psychometric properties of the resulting 36‐item test and assessed overall sample performance. Results The overall response rate was 27% (103 of 380). The test demonstrated good internal reliability (Cronbach &agr; = 0.66), with a mean score of 28.5 ± 3.4 out of the maximum 36. Participants with formal ethics training performed better than those without (30.3 ± 2.9 vs 28.1 ± 3.5; P = .01). Performance improved significantly with higher levels of medical/ethical training among the 5 groups: medical students, 25.9 ± 3.7; neonatal nurses/practitioners, 27.7 ± 2.7; neonatologists, 28.8 ± 3.7; neonatology fellows, 29.8 ± 2.9; and clinical ethicists, 33.0 ± 1.9 (P < .0001). Conclusions The TEK‐Neo reliably assesses knowledge of neonatal ethics among interprofessional staff and trainees in neonatology. This novel tool discriminates between learners with different levels of expertise and can be used interprofessionally to assess individual and group performance, track milestone progression, and address curricular gaps in neonatal ethics.