Rebecca Blankenburg

Stimulating Reflective Practice Among Your Learners

“There are three methods to gaining wisdom. The first is reflection, which is the highest. The second is imitation, which is the easiest. The third is experience, which is the bitterest.”Confucius Educational organizations, including the Council on Medical Student Education in Pediatrics, recognize that the development of the reflective practitioner is a fundamental element of professional training. The Royal College of Physicians and Surgeons of Canada articulate in their CanMEDS competency framework that physicians must “demonstrate a lifelong commitment to reflective learning” and “recognize and reflect learning issues in practice.”1 Similarly, the Accreditation Council for Graduate Medical Education requires graduating residents to continuously improve patient care based on constant self-evaluation and life-long learning.2 As part of the ongoing Council on Medical Student Education in Pediatrics series on skills and strategies used by great clinical teachers, this article focuses on reflection, a skill that should be modeled and taught to medical students so that they may practice and refine a reflective approach throughout their careers. Reflection means to “turn back” or think back on experiences. The definition takes on an added meaning when applied to clinical experiences and refers to the process of “slowing down” (not physically, but at an emotional or cognitive level) to analyze, in a deliberate manner, surprising or disconcerting events to make sense of them and understand why they occurred.3 Critical reflection occurs when one not only explores one’s own beliefs, biases, and approaches but also those of others who may have contributed to the way events unfolded. This may … Address correspondence to Lavjay Butani, MD, Department of Pediatrics, University of California Davis Medical Center, Ticon 2, Room 348, 2516 Stockton Blvd, Sacramento, CA 95817. E-mail: lbutani{at}ucdavis.edu

Exploring the Educational Value of Patient Feedback: A Qualitative Analysis of Pediatric Residents' Perspectives

From the Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford School of Medicine, Palo Alto, Calif (Ms Bogetz and Drs Rassbach, Chan, and Blankenburg); and Kaiser Permanente San Jose Medical Center, San Jose, Calif (Dr Chan) Conflict of Interest: The authors declare that they have no conflict of interest. Address correspondence to Alyssa L. Bogetz, MSW, Department of Pediatrics, Lucile Packard Children’s Hospital at Stanford School of Medicine, 725 Welch Rd, MC 5906, Palo Alto, CA 93404 (e-mail: abogetz@stanford.edu).

The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees.

Purpose Trainee mistreatment remains an important and serious medical education issue. Mistreatment toward trainees by the medical team has been described; mistreatment by patients and families has not. Motivated by discrimination towards a resident by a family in their emergency department, the authors sought to identify strategies for trainees and physicians to respond effectively to mistreatment by patients and families. Method A purposeful sample of pediatric faculty educational leaders was recruited from April–June 2014 at Stanford University. Using a constructivist grounded theory approach, semistructured one-on-one interviews were conducted. Participants were asked to describe how they would respond to clinical scenarios of families discriminating against trainees (involving race, gender, and religion). Interviews were audio-recorded, transcribed, and anonymized. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking. This project was IRB approved. Results Four themes emerged from interviews with 13 faculty: assess illness acuity, cultivate a therapeutic alliance, depersonalize the event, and ensure a safe learning environment. Participants wanted trainees to feel empowered to remove themselves from care when necessary but acknowledged that removal was not always possible or easy. Nearly all participants agreed that trainee and faculty development was needed. Suggested educational strategies included team debriefing and critical reflection. Conclusions Discrimination towards trainees by patients and families is an important issue. As this type of mistreatment cannot be fully prevented, effective preparation is essential. Effective response strategies exist and can be taught to trainees to empower responses that protect learners and preserve patient care.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Outcomes of a Randomized Controlled Educational Intervention to Train Pediatric Residents on Caring for Children With Special Health Care Needs

Objective. To evaluate an innovative curriculum meeting new pediatric residency education guidelines, Special Care Optimization for Patients and Education (SCOPE). Methods. Residents were randomized to intervention (n = 23) or control (n = 25) groups. Intervention residents participated in SCOPE, pairing them with a child with special health care needs (CSHCN) and faculty mentor to make a home visit, complete care coordination toolkits, and participate in case discussions. The primary outcome was resident self-efficacy in nine skills in caring for CSHCN. Secondary outcomes included curriculum feasibility/acceptance, resident attitudes, and family satisfaction. Results. Response rates were ≥65%. Intervention residents improved in their self-efficacy for setting patient-centered goals compared with controls (mean change on 4-point Likert-type scale, 1.36 vs 0.56, P < .05). SCOPE was feasible/acceptable, residents had improved attitudes toward CSHCN, and families reported high satisfaction. Conclusion. SCOPE may serve as a model for efforts to increase residents’ self-efficacy in their care of patients with chronic disease.

The Prevalence of Social and Behavioral Topics and Related Educational Opportunities During Attending Rounds

Purpose To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. Method This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes—prevalence of SBS topic discussions and rate of positive responses to discussions—were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. Results Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams’ responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. Conclusions Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

Continuing Education Needs of Pediatricians Across Diverse Specialties Caring for Children With Medical Complexity

Objective. Care for children with medical complexity (CMC) relies on pediatricians who often are ill equipped, but striving to provide high quality care. We performed a needs assessment of pediatricians across diverse subspecialties at a tertiary academic US children’s hospital about their continuing education needs regarding the care of CMC. Methods. Eighteen pediatricians from diverse subspecialties were asked to complete an online anonymous open-ended survey. Data were analyzed using modified grounded theory. Results. The response rate was 89% (n = 16). Of participants, 31.2% (n = 5) were general pediatricians, 18.7% (n = 3) were hospitalists, and 50% (n = 8) were pediatric subspecialists. Pediatricians recognized the need for skills in care coordination, giving bad news, working in interprofessional teams, and setting goals of care with patients. Conclusions. Practicing pediatricians need skills to improve care for CMC. Strategically incorporating basic palliative care education may fill an important training need across diverse pediatric specialties.

Resident Experiences With Implementation of the I-PASS Handoff Bundle

BACKGROUND The I-PASS Handoff Study found that introduction of a handoff bundle (handoff and teamwork training for residents, a mnemonic, a handoff tool, a faculty development program, and a sustainability campaign) at 9 pediatrics residency programs was associated with improved communication and patient safety. OBJECTIVE This parallel qualitative study aimed to understand resident experiences with I-PASS and to inform future implementation and sustainability strategies. METHODS Resident experiences with I-PASS were explored in focus groups (N = 50 residents) at 8 hospitals throughout 2012-2013. A content analysis of transcripts was conducted following the principles of grounded theory. RESULTS Residents generally accepted I-PASS as an ideal format for handoffs, and valued learning a structured approach. Across all sites, residents reported full adherence to I-PASS when observed, but selective adherence in usual practice. Residents adhered more closely when patients were complex, teams were unfamiliar, and during evening handoff. Residents reported using elements of the I-PASS mnemonic variably, with Illness Severity and Action Items most consistently used, but Synthesis by Receiver least used, except when observed. Most residents were receptive to the electronic handoff tool, but perceptions about usability varied across sites. Experiences with observation and feedback were mixed. Concern about efficiency commonly influenced attitudes about I-PASS. CONCLUSIONS Residents generally supported I-PASS implementation, but adherence was influenced by patient type, context, and individual and team factors. Our findings could inform future implementation, particularly around the areas of resident engagement in change, sensitivity to resident level, perceived efficiency, and faculty observation.

Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development

Background Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown. Objective We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types. Methods Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014. Results We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches. Conclusions Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.

Pediatric Resident Workload Intensity and Variability.

BACKGROUND: Research on resident workloads has focused primarily on the quantity of hours worked, rather than the content of those hours or the variability among residents. We hypothesize that there are statistically significant variations in resident workloads and better understanding of workload intensity could improve resident education. METHODS: The Stanford Children’s Health research database was queried for all electronic notes and orders written by pediatric residents from June 2012 to March 2014. The dataset was narrowed to ensure an accurate comparison among residents. A survey was used to determine residents’ self-perceived workload intensity. Variability of total notes written and orders entered was analyzed by χ2 test and a Monte Carlo simulation. Linear regression was used to analyze the correlation between note-writing and order-entry workload intensity. RESULTS: A total of 20 280 notes and 112 214 orders were written by 26 pediatric interns during 6 core rotations between June 2012 and June 2013. Both order-entry and note-writing workload intensity showed highly significant (P < .001) variability among residents. “High workload” residents, defined as the top quartile of total workload intensity, wrote 91% more orders and 19% more notes than “low workload” residents in the bottom quartile. Statistically significant correlation was observed between note-writing and order-entry workload intensity (R2 = 0.22; P = .02). There was no significant correlation between residents’ self-perceived workload intensity and their objective workload. CONCLUSIONS: Significant variations in workload exist among pediatric residents. This may contribute to heterogeneous educational opportunities, physician wellness, and quality of patient care.