Gerald B. Merenstein

Addressing the hidden curriculum: Understanding educator professionalism

Several authors agree that student observations of behaviors are a far greater influence than prescriptions for behavior offered in the classroom. While these authors stress the importance of modeling of professional relationships with patients and colleagues, at times they have fallen short of acknowledging the importance of the values inherent in the role of the professional educator. This includes relationships and concomitant behaviors that stem from the responsibilities of being an educator based on expectations of institutional and societal culture. While medical professionals share standards of medical practice in exercising medical knowledge, few have obtained formal training in the knowledge, skills and attitudes requisite for teaching excellence. Attention needs to be paid to the professionalization of medical educators as teachers, a professionalization process that parallels and often intersects the values and behaviors of medical practice but remains a distinct and important body of knowledge and skills unto itself. Enhancing educator professionalism is a critical issue in educational reform, increasing accountability for meeting student needs. Assumptions regarding educator professionalism are subject to personal and cultural interpretation, warranting additional dialogue and research as we work to expand definitions and guidelines that assess and reward educator performance.

Prospective validation of a scoring system for predicting neonatal morbidity after acute perinatal asphyxia

OBJECTIVE To prospectively validate a previously reported scoring system for identifying the near-term infant at risk for the multiple organ system sequelae of acute perinatal asphyxia. STUDY DESIGN Prospective observational study. SETTING Three Denver teaching hospitals, each providing comprehensive obstetric care. SUBJECTS Newborn infants of 36 weeks or more gestation. INTERVENTION None. STATISTICAL ANALYSIS Chi-squared analysis with Fishers exact test. OUTCOME Scores consisting of graded abnormalities in fetal heart rate monitoring, umbilical arterial base deficit, and 5-minute Apgar score were calculated by the research nurse after admission of the infant to the nursery (range of possible scores, 0 to 9). A second nurse, blinded to these data, prospectively followed the newborns hospital course for multiple organ system morbidity. RESULTS Three thousand two hundred thirty-eight newborns were studied; 366 required neonatal intensive care unit admission. Eleven newborns had a score > or = 6 (mean umbilical artery pH = 6.98, base deficit = 17.1 mEq/L). Morbidities in these 11 newborns included seizures (2), hypoxic-ischemic encephalopathy (5), respiratory distress (9), hypotension (7), renal dysfunction (9), hypoglycemia/hypocalcemia (4), and thrombocytopenia or disseminated intravascular coagulopathy (3). The odds ratio (OR) and 95% confidence interval (CI) for newborns admitted to the neonatal intensive care unit with a score > or = 6 for having multiple organ system morbidity, defined as three or more affected organ systems, was 38.5 (95% CI, 9.2 to 127.8). The scoring system showed a stronger relationship with multiple organ system morbidity than did isolated individual indicators commonly used to identify asphyxia calculated on the same subjects: for those with pH < 7.00, OR 24 (95% CI, 6.4 to 94.1); base deficit > or = 10 mEq/L, OR 4.5 (95% CI, 1.9 to 10.3), and 5-minute Apgar score < or = 3, OR 7.4 (95% CI, 1.3 to 38.1). CONCLUSION This scoring system, encompassing both immediate intrapartum and postpartum measures and acid-base status proximate to the time of delivery, is useful for rapidly identifying the term and near-term newborn at risk for multiple organ system morbidity after acute perinatal asphyxia.

Criteria for the discontinuation of antibiotic therapy during presumptive treatment of suspected neonatal infection.

Unstable newborns are often subjected to multiple diagnostic tests and then treated presumptively for bacterial infection. Inconclusive test results may perpetuate unnecessary therapy. One hundred twenty-three neonates were prospectively evaluated for infection. Complete physical examinations and chest radiographs were performed. Of ten screening tests only the white blood cell count, absolute band count, absolute band/neutrophil ratio and C-reactive protein showed statistical differences (P < 0.05) among 32 patients with positive “nonpermissive‘’ (blood, cerebrospinal fluid, suprapubic or catheter urine, needle aspirate, tracheal aspirate) cultures and 50 with negative cultures who had antibiotic therapy discontinued within 72 hours. Forty-one additional patients were continued on therapy despite negative cultures. Incomplete bacteriologic evaluation resulted in unconfirmed “pneumonia‘’ in 16 of these children. No statistical differences between the culture negative groups existed regardless of treatment status, suggesting that patients in the latter group may not have required continued treatment. A definitive, bacteriologic evaluation emphasizing “nonpermissive‘’ cultures should be completed in newborns suspected of infection which, when negative, should allow discontinuation of antibiotics. In equivocal cases, a negative C-reactive protein best supports cessation of therapy. This approach can reduce the total duration of newborn exposure to antibiotics in a high risk nursery by 20%. A prospective, definitive, diagnostic evaluation (emphasizing non-permissive cultures) avoids uninterpretable but frequently used tests and reduces cost while adding confidence in the termination of therapy.

Evaluation of Electronic Discussion Groups as a Teaching/Learning Strategy in an Evidence-based Medicine Course: A Pilot Study

BACKGROUND As course directors, we wished to incorporate small group learning into our Evidence-based Medicine course for students to get feedback on the development of a well constructed, researchable clinical question. Scheduling of these groups was problematic. We sought to evaluate computer-mediated communication as an alternative to face-to-face small groups. METHODS Students were randomly assigned to either face-to-face small groups or asynchronous, electronic, small groups. Final examination scores were analyzed with an analysis of variance to determine if there were differences in student performance based on group type. Student survey items were analyzed using Fishers Exact test to determine if there were differences in student attitudes based on group type. RESULTS There were no significant differences found in overall student performance. Significant differences in student attitudes were found to exist with respect to: (1) participation in discussions, with face-to-face groups reporting greater participation; (2) putting more thought into comments, with electronic groups reporting more thought put into comments; and (3) difficulty relating to other students in the class, with electronic groups reporting more difficulty. DISCUSSION We found electronic discussion groups (computer-mediated communication) to be a viable teaching/learning strategy with no adverse effects on student performance or attitudes.

A neonatal end-of-life palliative protocol--an evolving new standard of care?

IN 1979 THE CHILDREN’ S Hospital, Denver began to address the needs of the unfortunate group of infants who exhibit evidence of poor prognosis and for whom the question is raised whether any more should be done to prolong their lives.1 This program for the NICU was based on concepts first introduced and popularized by the hospice movement.2,3 It was recognized that generally NICU staff are concerned with neonatal survival—a rescue mode of care. Staff are often ill-equipped to provide adequate care to the family of the dying infant. This program proposed a new approach to the very difficult issues involved in the care of these very sick and dying infants. The Neonatal Hospice Program was a comprehensive plan focusing on four main areas: decisionmaking process and shift to palliative care, creation of a home-like, family room setting for the infant and family, involvement of family in the dying process and hospice training for NICU staff. Over the past 20 years, elements of this program have been implemented in many NICUs. However, the adaptation of a comprehensive program for palliative neonatal care has not been universally implemented. NICU staff and families of dying infants continue to seek change in hospital practice. Catlin and Carter have undertaken important research in exploring current trends in the care for the infant from whom life support is withdrawn or withheld.

Failure of tracheal aspirate cultures to define the cause of respiratory deteriorations in neonates.

The spectrum of organisms responsible for lower respiratory tract infection in chronically ventilated neonates is poorly defined. During an 18-month period 63 infants with a respiratory deterioration defined as an increase in fractional inspired O2 concentration ≥20% and/or mean airway pressure ≥3 cm H2O were evaluated for pulmonary infection. These infants were compared with 58 stable control ventilated infants. Tracheal aspirates for culture and Gram stain were taken from both groups and were cultured for bacteria, viruses, Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. In addition each infant had complete blood counts with differential and chest roentgenograms evaluated. Positive tracheal aspirates defined as a heavy growth of a single or two bacterial organisms, and/or any growth of virus, Chlamydia and U. urealyticum were found in 23 of 63 study patients and 20 of 58 controls (P > 0.05). The most frequent isolate in both groups was U. urealyticum. Chest radiographs were positive (new changes, particularly atelectasis and infiltrates) more frequently in the study group than in controls, but complete blood count and tracheal aspirate Gram-stained smears were not helpful in discerning colonization from infection. We conclude that positive tracheal aspirates occur with equal frequency among infants with a clinical suspicion of lower respiratory tract infection and in “well” controls. Chest roentgenogram may be a useful adjunctive test to discriminate between colonization and lower respiratory tract infection.

An evaluation of Bayesian microcomputer predictions of theophylline concentrations in newborn infants.

Determination of appropriate theophylline maintenance doses in preterm infants is confounded by interpatient variability. This study evaluated the performance of an IBM PC computer program applying Bayesian regression before and during steady state in 37 preterm infants. Prior population estimates of clearance and distribution volume in preterm infants and Bayesian estimates of clearance and distribution volume based on one to three theophylline plasma concentrations were used to predict subsequent concentrations (drawn 1–17 days later). We assessed the accuracy and precision of the predictive performance of the Bayesian program with the mean prediction error and the mean absolute prediction error. The absolute prediction error (mean absolute error ± SEM) significantly decreased with increasing feedback concentrations from 3.54 ± 0.45 μg/ml (population estimates) to 2.74 ± 0.42 (one feedback) and 2.02 ± 0.35 μg/ml (two feedback concentrations). Mean prediction errors (±SEM) based on one to three feedbacks (-1.5 ± 0.40 μ/ml) were significant improvements over population predictions (- 2.63 ± 0.72 μ/ml, p < 0.05), although a small but significant average overprediction remained. Absolute prediction error was correlated with postconceptional and postnatal age when zero or one but not two feedback concentrations were available. Computer program predictions based on one measured feedback concentration were more accurate and precise than population-based predictions. Refinement of population parameters or two feedback concentrations further improved performance.

IMPACT OF THE NIH CONSENSUS DEVELOPMENT CONFERENCE ON CORTICOSTEROIDS FOR FETAL MATURATION: CHANGE IN OBSTETRIC ATTITUDES. † 1506

IMPACT OF THE NIH CONSENSUS DEVELOPMENT CONFERENCE ON CORTICOSTEROIDS FOR FETAL MATURATION: CHANGE IN OBSTETRIC ATTITUDES. † 1506

The Child Heath Associate Physician Assistant Program — An Enduring Educational Model Addressing the Needs Of Families and Children

In contrast to what one might expect, this quote does not come from a recent medical journal. Forty years ago it provided a context for the development of three unique programs designed to address health care disparities and a predicted pediatric workforce shortfall. Henry K. Silver, MD, professor and vice-chairman of the Department of Pediatrics at the University of Colorado Health Sciences Center (UCHSC) addressed the needs of the country’s children by creating an innovative model for health care delivery, in part supported by new pediatric health care professionals who could support and complement the skills and training of their pediatrician colleagues. The first nurse practitioner (NP) program in the country was created in the Department of Pediatrics at the University of Colorado School of Medicine. The Pediatric Nurse Practitioner (PNP) program, launched as a joint venture by Dr. Silver (School of Medicine) and Loretta C. Ford, EdD, RN, PNP (School of Nursing), graduated its first students in 1965. This program, designed to increase the productivity of pediatricians, prepared nurses to assume an expanded role in providing comprehensive health services to children. The PNP was educated to provide almost total care for the well child as well as to manage the problems of the majority of sick and injured children commonly seen in a pediatric practice. The two schools also established a School Nurse Practitioner Program. Most are aware of the long-term impact of these visionary efforts, but few realize that they were also instrumental in the creation of the PA profession. Eugene Stead, MD, in a letter dated November 1, 1981, acknowledged Dr. Silver’s important contributions related to the creation of the NP profession: “Your statement about the chronology is correct. The demonAnita Duhl Glicken, MSW, is professor of pediatrics and interim director of the Child Health Associate/Physician Assistant Program; Gerald Merenstein, MD, is medical director and was director of the CHA/PA program for 12 years; and Mary Arthur, MS, CHA/PA, was a graduate of the second CHA/PA class and a longtime associate director of the CHA/PA program, University of Colorado at Denver and Health Sciences Center, Denver, Colorado.

Best evidence-based practices: a historic perspective.

Neonatologists, neonatal nurses, and others who care for critically ill newborns hope that the care they provide will improve the health and the neurodevelopmental outcome of these neonates. In this progressive era of neonatal medicine, we must pause to look backward even as we look forward, taking full advantage of the opportunity to reflect on our short history and to review several important events in neonatal medicine that have contributed in a meaningful way to the evolution of evidence-based neonatal care. Six interventions highlight why randomized controlled trials are necessary to understand the risks and benefits of our interventions with premature and critically ill infants. We hope this history of the evolving practice of evidence-based neonatal care will enable the reader to have a greater appreciation for the consideration of each and every intervention that we take on behalf of the infants in our care.