Michael A. Barone

PHACES (Photographs of Academic Clinicians and Their Educational Status): A Tool to Improve Delivery of Family-Centered Care

OBJECTIVE The aim of this study was to determine if an information sheet containing photographs and explanations of the training level of medical providers could enhance a parents ability to identify their childs providers and whether this would impact parental attitudes toward trainee involvement and patient satisfaction. METHODS This was a prospective, mixed methods study of parent-child dyads admitted to an academic general pediatric inpatient service. The intervention group received a photo information sheet (Photographs of Academic Clinicians and Their Educational Status [PHACES] tool) consisting of passport-sized photos of the medical team along with information regarding their training. Parents were asked to name their childs providers, were surveyed about their attitudes toward trainees, participated in a brief, semistructured interview and completed the patient satisfaction questionnaire (ABIM-PSQ). RESULTS Comparing intervention with control parents, 40 of 49 (82%) versus 19 of 51 (37%) were able to name at least one provider (adjusted odds ratio 8.0; P < .01). Parents who received the intervention were more likely to correctly match the face with the name of the medical student (67% vs 14%; P < .01) and attending (80% vs 24%; P < .01). Parents who received the intervention were more likely to report acceptance of the involvement of medical students and house staff as well as an improved understanding of their roles. Parents who received the intervention scored higher on the ABIM-PSQ (mean 48.3 vs 45.4; P = .008). CONCLUSIONS An information sheet containing the photographs of health care providers along with an explanation of their training improves recognition of the health care team members, improves acceptance of trainee involvement, and improves satisfaction with care delivered by physicians in training.

UTI: Diagnosis and Evaluation in Symptomatic Pediatric Patients:

We retrospectively reviewed data on 260 hospitalized pediatric patients with symptomatic urinary tract infection (UTI). To ascertain the colony-forming units (CFU) /mL compatible with the diagnosis of UTI, a culture from a catheterized urine specimen containing >1,000 CFU/mL was considered diagnostic of UTI and resulted in imaging by renal ultrasound, voiding cystourethrography, and renal nuclear scan with Tc99m dimercaptosuccinic acid (DMSA). A positive DMSA renal scan is indicative of pyelonephritis. We used logistic regression analysis to determine which patient characteristics were predictive of pyelonephritis. We determined that, in hospitalized pediatric patients, the colony count of the positive urine culture, the type of organism grown in culture, and the voiding cystourethrography (VCUG) result (positive or negative for vesicoureteral reflux) did not predict which patients had pyelonephritis. In females, advancing age of the patient and positive renal ultrasound results were predictive of which patients had pyelonephritis when we controlled for other factors. We feel this emphasizes the importance of a thorough evaluation of hospitalized symptomatic patients, including patients with colony counts of 1,000 to 50,000 CFU/mL, to locate the level of infection and plan appropriate therapy.

Evaluation of a simulation-based pediatric clinical skills curriculum for medical students.

Introduction Simulation-based education is expensive and requires greater resources than traditional methods, yet there is limited evidence to justify such expenditures for medical student education. Methods We describe the implementation and evaluation of a simulation-based curriculum delivered to medical students during a pediatric clerkship. This prospective mixed-methods study evaluated a 5-day long simulation-based clinical skills curriculum (PRE-Clerkship EDucational Exercises [PRECEDE]) at the Johns Hopkins University School of Medicine. Two hundred medical students participated in PRECEDE during a 2-year period and were compared with 236 students who had not. Outcomes were assessed across 3 levels of Kirkpatrick’s framework for evaluation. The 4-level model consists of reaction, learning, behavior, and results criteria. Secondary outcomes measured changes in assessment scores across 16 student performance domains during clerkship, changes in performance on the National Board of Medical Examiners subject examination in pediatrics, and student assessments of the curriculum. Results Improvements were noted across 3 levels of the Kirkpatrick’s model. Student performance evaluations were significantly higher across all 16 evaluation components, with effect sizes ranging from small to medium (Cohen’s d, 0.23–0.44). Students scored significantly higher on the National Board of Medical Examiners pediatric shelf examination (80 vs. 77, P < 0.001). Ninety-seven percent of the medical students agreed that their skills increased and that the time lost to real clinical experiences was a worthwhile trade-off for this curriculum Conclusions The implementation of a simulation-based curriculum within a pediatrics clerkship resulted in higher knowledge scores and led to improvements in medical student clinical performance during the clerkship.

Setting Standards to Determine Core Clerkship Grades in Pediatrics

OBJECTIVE One of the greatest challenges for clerkship directors is assigning a final grade and determining the precise point at which a student either passes or fails a clinical clerkship. The process of incorporating both subjective and objective assessment data to provide a final summative grade can be challenging. We describe our experience conducting a standard-setting exercise to set defensible cut points in a 4-tiered grading system in our pediatric clerkship. METHODS Using the Hofstee standard-setting approach, 8 faculty members participated in an exercise to establish grade cut points. These faculty members were subsequently surveyed to assess their attitudes toward the standard-setting process as well as their reactions to these newly proposed standards. We applied the new cut points to a historic cohort of 116 Johns Hopkins University School of Medicine students from the academic year 2012-2013 to assess the potential impact on grade distributions. RESULTS The resultant grading schema would lead to a significant increase in the number of students receiving a failing grade and a decrease in the number of students receiving a grade of honors in a historical cohort. Faculty reported that the Hofstee method was easy to understand and fair. All faculty members thought that grade inflation presently exists within the pediatric clerkship. CONCLUSIONS This study demonstrates that practical standards using the Hofstee method can be set for medical students in a pediatric clerkship in which multiple performance measures are used.

Improving teaching on an inpatient pediatrics service: a retrospective analysis of a program change

BackgroundThe traditional role of the faculty inpatient attending providing clinical care and effectively teaching residents and medical students is threatened by increasing documentation requirements, pressures to increase clinical productivity, and insufficient funding available for medical education. In order to sustain and improve clinical education on a general pediatric inpatient service, we instituted a comprehensive program change. Our program consisted of creating detailed job descriptions, setting clear expectations, and providing salary support for faculty inpatient attending physicians serving in clinical and educational roles. This study was aimed at assessing the impact of this program change on the learners’ perceptions of their faculty attending physicians and learners’ experiences on the inpatient rotations.MethodsWe analyzed resident and medical student electronic evaluations of both clinical and teaching faculty attending physician characteristics, as well as resident evaluations of an inpatient rotation experience. We compared the proportions of “superior” ratings versus all other ratings prior to the educational intervention (2005–2006, baseline) with the two subsequent years post intervention (2006–2007, year 1; 2007–2008, year 2). We also compared medical student scores on a comprehensive National Board of Medical Examiners clinical subject examination pre and post intervention.ResultsWhen compared to the baseline year, pediatric residents were more likely to rate as superior the quality of didactic teaching (OR=1.7 [1.0-2.8] year 1; OR=2.0 [1.1-3.5] year 2) and attendings’ appeal as a role model (OR=1.9 [1.1-3.3] year 2). Residents were also more likely to rate as superior the quality of feedback and evaluation they received from the attending (OR=2.1 [1.2-3.7] year 1; OR=3.9 [2.2-7.1] year 2). Similar improvements were also noted in medical student evaluations of faculty attendings. Most notably, medical students were significantly more likely to rate feedback on their data gathering and physical examination skills as superior (OR=4.2 [2.0-8.6] year 1; OR=6.4 [3.0-13.6] year 2).ConclusionsA comprehensive program which includes clear role descriptions along with faculty expectations, as well as salary support for faculty in clinical and educational roles, can improve resident and medical student experiences on a general pediatric inpatient service. The authors provide sufficient detail to replicate this program to other settings.

Taking humanism back to the bedside

After attending The Arnold P. Gold Foundation’s “Barriers to Sustaining Humanism in Medicine” symposium in 1996, Steve Miller and Richard Sarkin proposed a Traveling Fellows program for the foundation. The program was approved, and Steve and Rich served as the program’s 2 Traveling Fellows until their untimely death on October 19, 2004. Steve and Rich, both Council on Medical Student Education in Pediatrics presidents known for their creativity and charisma, brought to our collective consciousness the need to promote humanism in our work as clinicians, teachers, and role models. When they died, Steve’s Chair at Columbia, John Driscoll, urged that their memory be honored by devoting time each October to promoting humanism.1 It is in this spirit that COMSEP Perspectives provides the following article. – Kenneth B. Roberts, MD Reflecting on our journey through medicine, we may recall pivotal moments that re-affirmed our commitment to the values of our profession. These moments may relate to the spirit of discovery inherent in the practice of medicine, to the recognition afforded by society to medical practitioners, or to service toward those who are suffering and in need of care. This last attribute, which encompasses a spirit of sincere concern for the centrality of human values in every … Address correspondence to Jennifer Plant, MD, MEd, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817. E-mail: jplant{at}ucdavis.edu

Assessing and Remediating Clinical Reasoning

Trainees must have excellent clinical reasoning skills to practice medicine safely and effectively. Even when a trainee has an impressive knowledge base, he or she can have difficulty applying that knowledge to patient problems. In this chapter, the authors discuss how the cognitive processes involved in decision-making apply in medicine. They propose a framework for how educators can teach and model decision-making to medical trainees based on the literature and their extensive experience with novice clinicians. They propose that learners should manifest progress of clinical reasoning in four ways: (1) an improved ability to develop and share a concise verbal or written problem representation; (2) an increasing and consistent use of semantic qualifiers; (3) the ability to state, seek, identify, and recall the defining and discriminating features of a patient’s history and physical exam and link this to their knowledge base of “illness scripts” and (4) demonstrate an increasing metacognitive awareness which reduces cognitive biases in patient evaluations. They provide detailed descriptions of an array of strategies to address immature clinical reasoning.

Recruitment and Retention of Community Preceptors

We provide an analysis of the challenges and proposed solutions in recruiting and retaining community preceptors from the viewpoint of pediatric department chairs. BACKGROUND: Recruiting and retaining community-based pediatricians for teaching medical students has been explored through the lens of preceptors and educational leaders. The purpose of this study was to explore the perspective of pediatric department chairs, a key stakeholder group charged with maintaining teaching capacity among a faculty. METHODS: In 2015, members of the Association of Medical School Pediatric Department Chairs and Council on Medical Student Education in Pediatrics joint task force disseminated a 20-item survey to pediatric department chairs in the United States and Canada. Topics included demographics, incentives offered to community pediatricians, and the perceived value and feasibility of such incentives. Data were analyzed using descriptive statistics and χ2 to compare categorical variables. RESULTS: Pediatric department chairs from 92 of 145 (63% response rate) medical schools returned the survey. Sixty-seven percent reported difficulty recruiting or retaining preceptors, and 51% reported high-reliance on preceptors for the ambulatory portion of the pediatrics clerkship. Almost all (92%) cited competition from other programs for the services of community preceptors. The provision of incentives was correlated with perceived feasibility (R2 = 0.65) but not their perceived value (R2 = 0.12). Few (21%) chairs reported providing financial compensation to preceptors. The provision of compensation was not related to reliance but did vary significantly by geographical region (P < .001). CONCLUSIONS: Pediatric departments rely heavily on community-based pediatricians but face competition from internal and external training programs. The perspective of department chairs is valuable in weighing interventions to facilitate continued recruitment and retention of community preceptors.

Growth Module in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum

Introduction The Johns Hopkins Pediatrics Clerkship developed this growth module as part of the PRECEDE (preclerkship educational exercises) curriculum, with the primary goal of providing students with experiential, explicit, and standardized instruction in essential pediatric clinical skills to better prepare them to utilize these skills during their clerkship. Methods This 2-hour growth module begins with a 45-minute didactic overview of growth, including discussion of normal growth, normal variants of growth, and disorders that affect growth, and contains interactive elements to engage the students. Students then divide into groups of four to six, each with a faculty facilitator to work through three cases in a guided discussion to explore specific aspects of growth that may be encountered in a pediatric evaluation. Results In a survey of 238 students, 97–100% agreed or strongly agreed with eight positive assessments of the module. Likewise, 79% of students rated the module as excellent, the remainder rating the module as good. Discussion From the perspectives of students and instructors, the implementation of this new module was very successful in its delivery of educational content. These cases were designed to give the students experience in plotting growth parameters against normative data and to gain familiarity with pediatric growth curves in order to identify growth abnormalities. The cases also aimed to reinforce the importance of using growth data in pediatric patients in order to both generate a differential diagnosis for a growth disorder and to modify a differential diagnosis generated by a chief complaint based on growth data.

How to "engage" multilevel learner groups in the clinical setting

* Abbreviations: IVIg — : intravenous immunoglobulin KD — : Kawasaki disease MLL — : multilevel learner In many clinical settings, multiple trainees work alongside a single preceptor. Not surprisingly, there is great variability in the knowledge and skills of medical students, residents, fellows, and other health professions trainees. In such settings, it can be challenging to engage the entire team while avoiding teaching that any particular trainee would perceive as too elementary or too complex. Thus, great clinical teachers employ strategies to develop different learners’ clinical skills and independence. Unfortunately, not much information is available on this topic, and clinical teachers may only find effective teaching strategies for such multilevel learner (MLL) groups by trial and error.1–4 A quick assessment of learners’ needs and educational levels forms the foundation of teaching MLLs. When joining an inpatient team or starting a day in the outpatient clinic, the great clinical teacher finds out who are the medical, physician assistant, nursing, or therapy students and who are the interns, senior residents, or fellows. Experienced preceptors seek opportunities to talk with learners one-to-one, ask about their interests, and work with them to develop 1 or 2 specific learning goals. Great teachers ask skillful questions to gain insight into each learner’s unique experiences, knowledge base, and adeptness with clinical reasoning.5 … Address correspondence to Patricia D. Quigley, MD, MME, Johns Hopkins All Children’s Hospital, Office of Medical Education, 601 5th Ave S, Saint Petersburg, FL 33701. E-mail: patricia.quigley{at}jhmi.edu