Lynn C. Garfunkel

Neonatal Circumcision and Pain Relief: Current Training Practices

Objective. We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. Methods. Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). Results. Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02–0.08] or obstetrical (OR, 0.14; 95% CI, 0.08–0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3–110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4–306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7–7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7–4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. Conclusions. Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Discordance Between Resident and Faculty Perceptions of Resident Autonomy: Can Self-determination Theory Help Interpret Differences and Guide Strategies for Bridging the Divide?

Purpose To identify and interpret differences between resident and faculty perceptions of resident autonomy and of faculty support of resident autonomy. Method Parallel questionnaires were sent to pediatric residents and faculty at the University of Rochester Medical Center in 2011. Items addressed self-determination theory (SDT) constructs (autonomy, competence, relatedness) and asked residents and faculty to rate and/or comment on their own and the other group’s behaviors. Distributions of responses to 17 parallel Likert scale items were compared by Wilcoxon rank-sum tests. Written comments underwent qualitative content analysis. Results Respondents included 62/78 residents (79%) and 71/100 faculty (71%). The groups differed significantly on 15 of 17 parallel items but agreed that faculty sometimes provided too much direction. Written comments suggested that SDT constructs were closely interrelated in residency training. Residents expressed frustration that their care plans were changed without explanation. Faculty reported reluctance to give “passive” residents autonomy in patient care unless stakes were low. Many reported granting more independence to residents who displayed motivation and competence. Some described working to overcome residents’ passivity by clarifying and reinforcing expectations. Conclusions Faculty and residents had discordant perceptions of resident autonomy and of faculty support for resident autonomy. When faculty restrict the independence of “passive” residents whose competence they question, residents may receive fewer opportunities for active learning. Strategies that support autonomy, such as scaffolding, may help residents gain confidence and competence, enhance residents’ relatedness to team members and supervisors, and help programs adapt to accreditation requirements to foster residents’ growth in independence.

Global health education in US pediatric residency programs

BACKGROUND AND OBJECTIVE: Despite the growing importance of global health (GH) training for pediatric residents, few mechanisms have cataloged GH educational opportunities offered by US pediatric residency programs. We sought to characterize GH education opportunities across pediatric residency programs and identify program characteristics associated with key GH education elements. METHODS: Data on program and GH training characteristics were sought from program directors or their delegates of all US pediatric residency programs during 2013 to 2014. These data were used to compare programs with and without a GH track as well as across small, medium, and large programs. Program characteristics associated with the presence of key educational elements were identified by using bivariate logistic regression. RESULTS: Data were collected from 198 of 199 active US pediatric residency programs (99.5%). Seven percent of pediatric trainees went abroad during 2013 to 2014. Forty-nine programs (24.7%) reported having a GH track, 66.1% had a faculty lead, 58.1% offered international field experiences, and 48.5% offered domestic field experiences. Forty-two percent of programs reported international partnerships across 153 countries. Larger programs, those with lead faculty, GH tracks, or partnerships had significantly increased odds of having each GH educational element, including pretravel preparation. CONCLUSIONS: The number of pediatric residency programs offering GH training opportunities continues to rise. However, smaller programs and those without tracks, lead faculty, or formal partnerships lag behind with organized GH curricula. As GH becomes an integral component of pediatric training, a heightened commitment is needed to ensure consistency of training experiences that encompass best practices in all programs.

Educating residents in behavioral health care and collaboration: Comparison of conventional and integrated training models

Purpose To determine whether former pediatric residents trained using a model of integrated behavioral health (BH) care in their primary care continuity clinics felt more comfortable managing BH care and better prepared to collaborate with BH professionals than did peers from the same residency who trained in clinics with a conventional model of BH care. Method University of Rochester School of Medicine and Dentistry pediatric residents were assigned to one of two continuity clinic sites. At one site, psychology fellows and faculty were integrated into the clinic teams in the mid-1990s. At the other, conventional patterns of consultation and referral continued. In 2004, the authors surveyed 245 alumni (graduated 1989–2003) about their experiences and their comfort with providing BH care and collaborating with BH providers in their current practice. Results A total of 174 alumni (71%) responded. There were significant differences between graduates who trained in the two models. Those who trained in the integrated model were significantly more likely than others to report that they had consulted or planned treatment with a BH provider during residency and to report that their continuity clinic helped prepare them to collaborate with BH providers. They were somewhat more likely to believe that their overall residency training prepared them to manage BH issues in their current practice. Conclusions These findings suggest that an integrated training environment, described in detail in the companion article in this issue, can enhance pediatric resident education in the management of BH problems and collaboration with BH specialists.

Professionalism in Practice: Strategies for Assessment, Remediation, and Promotion

The Council on Medical Student Education in Pediatrics continues its series on great clinical teachers, focusing on professionalism in practice. The Council on Medical Student Education in Pediatrics is in agreement with the Liaison Committee on Medical Education, Accreditation Council on Graduate Medical Education, and the CanMEDS Physician Competency Framework, that professionalism is essential to the practice of medicine, regardless of the level of training. Clinical teachers are in an excellent position to promote and assess professional behaviors in students but are often hesitant to address lapses in professionalism; however, addressing professionalism early is critical, as professional misbehavior in medical school is a major risk factor for subsequent censure by state medical boards.1 This article discusses tools and strategies for the assessment, remediation, and promotion of professionalism in medical students. Many practitioners say, “I know it when I see it,” but defining professionalism can be challenging. Professionalism is built on the principles of excellence, humanism, accountability, and altruism and is demonstrated through clinical competence, communication, and ethical understanding.2 Humanism and altruism encompass beneficence, respect, truthfulness, and placing the needs of the patient above ones own. Excellence and accountability include striving for high-quality patient care, making a commitment to lifelong learning, and exhibiting responsibility to duty. Professional maturity requires the development of these behaviors through deliberate practice so that they become the habits that define a good physician. Evaluating professionalism is the responsibility of every clinical teacher. Assessable components include adherence to ethical practice principles, effective interactions with patients and the people who are important to these patients, effective interactions with individuals within the health care system, reliability and accountability, and commitment to improvement.3 The development of professionalism in medical … Address correspondence to April O. Buchanan, MD, Department of Pediatrics, University of South Carolina School of Medicine, Greenville Hospital System University Medical Center, 701 Grove Rd, 4th Floor Balcony Suites, Greenville, SC 29605. E-mail: abuchanan{at}ghs.org

Expanding the pediatrics residency curriculum.

No abstract available.

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.

Case-Based Workshop for Teaching Child Abuse Prevention to Resident Physicians

Introduction Child abuse is a ubiquitous problem with personal, interpersonal, and social consequences. Risk factors are well established, and preventive strategies have been effective in decreasing abusive parenting behaviors and child maltreatment incident reports. Curriculum tools are needed to incorporate these strategies into training programs so physicians are adequately trained to identify and prevent child maltreatment at the earliest opportunity. Methods A literature review established the core content for the curriculum. Resident learning needs were assessed with an online survey sent to graduating residents and teaching faculty. Curriculum objectives were composed to target core content and to address learning needs. Adult learning theories were applied to design interactive, case-based workshops to meet the curriculum objectives. A qualitative assessment tool was distributed to participating residents pre- and postcurriculum. Evaluators were blinded to pre/post status. Follow-up surveys distributed 3 months after the curriculum evaluated for retention of content and application to clinical practice. Results After workshop participation, residents showed a greater tendency to associate somatic and behavioral complaints with potential toxic stress or abuse and demonstrated understanding of ongoing needs and risks in affected families. On follow-up surveys, most residents self-reported progress toward incorporating discussion of risk factors, stress, and abuse into routine well-child visits. Discussion Resident physicians who attended the child abuse prevention workshop acquired knowledge and skills relevant to secondary and tertiary child abuse prevention and indicated progress toward primary prevention goals during the subsequent 3 months.

Practice Procedures in Models of Primary Care Collaboration for Children With ADHD.

Introduction: With nationwide movement toward an integrated medical home, evidence to support, compare, and specify effective models for collaboration between primary care and behavioral health professionals is essential. This study compared 2 models of primary care with behavioral health integration on American Academy of Pediatrics guideline adherence for attention-deficit/hyperactivity disorder (ADHD) assessment and treatment. Method: We conducted a retrospective chart review of a random sample of children aged 6–13 years, seen for ADHD services in 2 primary care offices, 1 fully integrated model and 1 co-located service only model, comparing ADHD assessment and treatment practices. We used chi-square analyses and logistic regression modeling to determine differences by type of health care model. Results: Among children with ADHD (n = 149), the integrated care model demonstrated higher rates of guideline adherence, more direct contact with schools, and more frequent behavioral observation during clinical encounters. Families in the integrated practice received more caregiver education on ADHD, behavioral management training, and school advocacy, however, these associations did not remain after accounting for variance associated with onsite engagement with a psychologist. Practices were equivalent on use of medication and psychiatric consultation, although, more families in the integrated practice engaged with a psychologist and attended more frequent medication follow-up appointments than those in the co-located practice. Discussion: This study is among the first to compare different levels of collaborative care on practice procedures. Understanding how we can best integrate between behavioral health and primary care services will optimize outcomes for children and families.