Raquel G. Hernandez

Parents’ Healthy Weight Perceptions and Preferences Regarding Obesity Counseling in Preschoolers: Pediatricians Matter

Objective: To compare parental report of child body image with perceived healthy weight body image in preschoolers and describe weight-counseling preferences. Methods: Parents seeking well-child care were interviewed and asked to select images resembling: (a) their own child’s current weight, (b) a healthy weight preschooler, and (c) friend and family report of a healthy weight preschooler. Those indicating that their overweight or obese child resembled a healthy weight image were considered to misclassify child weight. Logistic regression was used to identify predictors of misclassification and card-sorting exercises explored weight-counseling preferences. Results: Of the 150 preschoolers in our sample, 32.7% (n = 49) were overweight or obese with misclassification occurring in 71.4% of parents (n = 35). Absence of pediatrician comment on child weight strongly predicted misclassification (odds ratio, 12.3; 95% confidence interval, 1.74-87.2). Pediatricians were highly valued weight advisors. Conclusions: Weight-focused advice from pediatricians matters to parents and may promote parental identification of early childhood weight risks.

Insect Bite–Induced Hypersensitivity and the SCRATCH Principles: A New Approach to Papular Urticaria

Insect bites and the associated hypersensitivity reactions known as papular urticaria account for a significant number of all referrals from pediatricians and dermatologists to our pediatric dermatology clinic. Unfortunately, children affected by these eruptions are frequently misdiagnosed and often subject to expensive evaluations including invasive and unnecessary procedures. Here we review the course of 4 children with the typical physical findings and natural history of these reactions. On the basis of our clinical findings and experience with this patient population, we propose a set of principles (termed “SCRATCH”) as clinical features to aid clinicians in making an early and accurate clinical diagnosis. We conclude that a more appropriate term for future study and diagnosis of this entity is insect bite–induced hypersensitivity.

Caring for patients with limited English proficiency: are residents prepared to use medical interpreters?

Purpose To evaluate whether educational sessions on interpreter use and experience with interpreters are associated with resident self-efficacy in the use of professional interpreters. Method In 2010, the authors surveyed residents from seven pediatric residency programs. Their 29-item survey collected data on training and experience with interpreters and self-efficacy in (1) determining when an interpreter is needed and (2) using a professional interpreter. The authors conducted bivariate and multivariate regression analyses. Results Among the 271 respondents, 82% reported that ≥ 10% of their patients had limited English proficiency (LEP), 53% indicated they had “a lot” of experience with interpreters, and 54% reported never receiving any educational sessions on interpreter use. The majority reported high self-efficacy in knowing when an interpreter is needed (69%) and in using an interpreter (68%). Residents reporting a high experience level with interpreters were more likely to report high self-efficacy in knowing when an interpreter is needed (odds ratio [OR] = 1.85; 95% confidence interval[CI] = 1.03–3.32) and in using an interpreter (OR = 3.97; 95% CI = 1.19–13.31). Formal training on using interpreters was also associated with high self-efficacy in interpreter use(OR = 1.62; 95% CI = 1.22–2.14). Conclusions Many residents who care for patients with LEP have never received educational sessions on interpreter use. Such training is associated with high self-efficacy and may enhance patient–provider communication. Incorporating this training into residency programs is necessary to equip providers with skills to communicate with patients and families with LEP.

The evolution of graduate medical education over the past decade: Building a new pediatric residency program in an era of innovation

Abstract Aim: In 2011, Johns Hopkins Medicine integrated with All Childrens Hospital in St. Petersburg Florida to create an academic campus nearly 1000 miles from Baltimore. In 2014, the newly named Johns Hopkins All Childrens Hospital established a new pediatric residency program. At that time, the Association for Graduate Medical Education had not accredited a new pediatric program in the USA in over 10 years. Methods: A unique set of circumstances provided an opportunity for program developers to build the residency under newly identified core tenets to create a number of innovative features targeted to address the many calls for change in graduate medical education. Results: This paper focuses on three of those innovations and demonstrates how they address the many challenges introduced by the changing landscape of graduate medical education. Conclusion: Although a full evaluation of our program is only possible after many years, this article presents the core tenets which guided curricular development and discusses our experiences thus far. We provide lessons learned for programs considering similar innovations.

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs

Introduction Difficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described. Materials and methods We used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents’ experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results. Results These survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as “fair” or “good” (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters. Discussion We found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors. Conclusions Next steps include creating a “Difficult Encounters” communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

In reply to Drain and Rhatigan

We appreciate the insightful comments from Drs. Drain and Rhatigan regarding our article. Their observation that our findings may overestimate residents’ proficiency with interpreters reemphasizes our study’s central conclusion: that the low rate of education and evaluation on interpreter use, even among residency programs where exposure to individuals with limited English proficiency (LEP) is relatively high, suggests that broad action in this area is needed. We believe that as the population with LEP increases and the striking demand for global health experiences grows,1 the need to uniformly train physicians in interpreter use is substantiated regardless of a program’s local population demographics. Supporting this call for action is our finding that educational sessions on interpreter use during residency are associated with increased resident self-efficacy in this domain. Equally important is a finding reported by Hernandez et al2 that self-efficacy in the overall care of families with LEP is associated with increased resident satisfaction in the care of such families. We agree with Drain and Rhatigan that training in global health is important and add that interpreter training relates to both the care of individuals with LEP in the United States and to experiences with international populations. Given that training in cross-cultural care is now a residency program expectation,3 we propose that training in the areas of global health and caring for individuals with LEP may have a greater impact when combined in scope. They also may be better accepted and more effective when introduced earlier in training, such as throughout the medical school curriculum.