R. Franklin Trimm

Spontaneous motor activity in the perinatal infant before and after birth: Stability in individual differences

This study was undertaken to determine if a relationship existed between the duration of spontaneous general movements before and after birth. Twenty-two infants were examined three times as fetuses between 38 and 40 weeks gestational age and three times as neonates between 2 and 4 weeks postnatal age. Motor activity level during active sleep periods was quantified by direct sonographic visualization for fetuses and by videotaped images of trunk movement for neonates. We found that both fetuses and neonates exhibited stable individual differences in motor activity level. In addition, infants who moved at a certain rate as fetuses generally moved at the same relative rate as neonates up to 4-weeks postnatal age. Our findings suggested that individual differences in motor activity level in the 1st month following birth probably arise during fetal life.

Temporal stability in the distribution of behavioral states for individual human fetuses

Although behavioral state analyses have been useful in differentiating between groups of normal and at-risk fetuses, the large between-subject differences in the percent time spent in the various behavioral states poses a major obstacle in identifying abnormal neurological functioning in individual fetuses. Does this variability represent a true difference in state organization between fetuses, or does it simply reflect individual fluctuations in state control at the time of observation? To answer this question, we examined each of 33 human fetuses for 4 h on three separate days between 38 and 40 weeks gestation. The percent time spent in each behavioral state and in transition and insertion periods was determined for each of the three 4-h study sessions, and within-subject analysis of variance was performed to obtain an objective measure of state profile consistency for each fetus. We found that, on the average, fetuses exhibited remarkable within-subject consistency in their state profiles. However, even among this group of low-risk fetuses, there were significant differences in the degree of state organization achieved by individual fetuses. These findings, which indicate the existence of a well-developed central nervous system before birth, suggest that individual differences in the consistency of behavioral state profiles may be indexing important between-subject differences in neurological development.

One specialty's collaborative approach to competency-based curriculum development.

The authors describe a seven-step consensus development process used to create the two most recent editions of the Academic Pediatric Associations (APAs) educational guidelines for pediatric residency. The 1996 (printed) and 2004 (online) editions of the guidelines were designed as flexible tools to help residency programs meet changing accreditation requirements by providing lists of goals and objectives and objective-based evaluation tools. The guidelines were developed in seven steps: (1) centralized national leadership combined with coordinated, disseminated authorship, (2) clear definition of targeted users and repeated assessment of their needs, (3) incorporation of up-to-date information from the literature and national experts, (4) responsive consultation with the national Pediatric Residency Review Committee on the latest accreditation requirements, (5) wide distribution for prepublication review, to obtain broad organizational buy-in and end-user acceptance, (6) intensive dissemination and faculty development through multiple national workshops over several years, and (7) careful evaluation of utilization and user feedback. Representatives of all major organizations involved in pediatric education helped to refine the guidelines. User surveys conducted for the 1996 edition, and Web site user data collected for the 2004 edition, demonstrate that both editions have been used by most residency programs throughout the country. The authors believe that the multifaceted approach to consensus development and the customizable design of the curricular tools in the APAs guidelines are directly associated with their broad national use. These methods may help to guide educators in other disciplines who are interested in developing and implementing educational products for national dissemination and use.

Evaluation of the use of an interactive, online resource for competency-based curriculum development

Purpose To evaluate pediatric educators’ use of and satisfaction with the Academic Pediatric Association’s Educational Guidelines for Pediatric Residency. Method The authors used customized programming to document all registered users and downloaded files from the Guidelines Web site for a 30-month period after site completion. An online survey of volunteer users was conducted. Results Between July 2005 and December 2007, 1,747 individuals registered on the Web site, and 8,754 files were downloaded. Registrants who downloaded files (n = 1,239) represented 97% of the pediatric residency programs in 2008 that were approved by the Accreditation Council for Graduate Medical Education. During 30 months, the frequency of downloads remained robust, peaking each spring. Curriculum-building tools were downloaded by 97% of programs using the site; the majority chose predesigned formats rather than self-selected lists of goals and objectives. Resident evaluation forms and tutorials were downloaded less frequently. A survey was completed by 111 site users, who indicated that the Guidelines tools were useful for Residency Review Committee site visit preparation. Most respondents said that the curriculum-building tools were easy to use, adaptable, and helpful in integration of competencies into residency programs. Respondents rated tutorials highly for educational content and clarity. Conclusions The data collection methods offer a practical strategy for evaluating access to online curriculum development tools. The majority of U.S. pediatric residency programs have accessed Guidelines’ resources for curriculum development; patterns of use have been sustained over time. Most users preferred the predesigned versions of the materials. Users surveyed found the tools useful for planning rotations and integrating competencies into their programs and reported high satisfaction with the Guidelines.

Identifying Gaps in the Performance of Pediatric Trainees Who Receive Marginal/Unsatisfactory Ratings.

Purpose To perform a derivation study to determine in which subcompetencies marginal/unsatisfactory pediatric residents had the greatest deficits compared with their satisfactorily performing peers and which subcompetencies best discriminated between marginal/unsatisfactory and satisfactorily performing residents. Method Multi-institutional cohort study of all 21 milestones (rated on four or five levels) reported to the Accreditation Council for Graduate Medical Education, and global marginal/unsatisfactory versus satisfactory performance reported to the American Board of Pediatrics. Data were gathered in 2013–2014. For each level of training (postgraduate year [PGY] 1, 2, and 3), mean differences between milestone levels of residents with marginal/unsatisfactory and satisfactory performance adjusted for clustering by program and C-statistics (area under receiver operating characteristic curve) were calculated. A Bonferroni-corrected significance threshold of .0007963 was used to account for multiple comparisons. Results Milestone and overall performance evaluations for 1,704 pediatric residents in 41 programs were obtained. For PGY1s, two subcompetencies had almost a one-point difference in milestone levels between marginal/unsatisfactory and satisfactory trainees and outstanding discrimination (≥ 0.90): organize/prioritize (0.93; C-statistic: 0.91) and transfer of care (0.97; C-statistic: 0.90). The largest difference between marginal/unsatisfactory and satisfactory PGY2s was trustworthiness (0.78). The largest differences between marginal/unsatisfactory and satisfactory PGY3s were ethical behavior (1.17), incorporating feedback (1.03), and professionalization (0.96). For PGY2s and PGY3s, no subcompetencies had outstanding discrimination. Conclusions Marginal/unsatisfactory pediatric residents had different subcompetency gaps at different training levels. While PGY1s may have global deficits, senior residents may have different performance deficiencies requiring individualized counseling and targeted performance improvement plans.