Robert S. McGregor

e-Professionalism: Challenges in the Age of Information

averse industry in the United States,’’ according to Christensen. The age of information clearly has affected the culture of medicine in ways that we are just beginning to understand. Never before have there been so many ways to communicate. In the past, we were limited to face-to-face conversations, postal mail, telegrams, and telephone calls. Physicians communicated about their credentials through listings in the telephone book and in local medical society publications, or by hanging a shingle outside the office. With the development and diffusion of new technologies, our means of communicating about ourselves, as well as with colleagues, patients, families, and learners grew enormously. At the same time, the types of new technologies expanded; e-mail, video conferences, webinars, text messaging, text pagers, websites, blogs, and social networking sites all entered our culture within the past 20 years. The use of these technologies is pervasive and increasing. Professionalism, as one of the core competencies established by the Accreditation Council of Graduate Medical Education (ACGME), has been the subject of much discussion in the last several years. The American Board of Internal Medicine developed a charter for medical professionalism in the new millennium that articulated fundamental principles and a set of professional responsibilities. 2 The American Board of Pediatrics, in conjunction with the Association of Pediatric Program Directors, developed a guidebook for teaching and assessing professionalism in pediatric residency that set forth specific examples of exemplary behavior, lapses in professionalism, and behaviors that warrant immediate attention. 3 Although much has been written and discussed about this subject recently, it is notable that the subject of professionalism in electronic communication, e-Professionalism, has not been addressed. Examples of lapses in professionalism in the electronic realm are just beginning to be appreciated. Personal cellular phones may be used for professional communication, which challenges the boundaries of patient confidentiality and may lead to blurred hierarchical roles between faculty and learners in education and clinical care. Physicians posting on online social networking sites must be reminded that their professionalism may be judged by such content. For example, photographs, social group affiliations, and personal information that are not generally shared in the doctor-patient relationship may be inadvertently revealed to patients via postings on social networking sites. In 2008, Thompson et al 4 at the University of Florida studied Facebook pages of medical students and residents and found that 46.3% of medical students and 12.8% of residents had accounts. A majority of the accounts were not private and, in some cases, there was inappropriate or unprofessional content posted. At a recent meeting of pediatric program directors, Matz et al 5 facilitated a workshop on e-Professionalism and began to illuminate this developing issue. At this workshop, the 3 that characterize electronic professionalism were coined: electronic communication is Public, Permanent, and Powerful.

Differential diagnosis of chest symptoms in the athlete

Chest pain is a common complaint of athletes in all age groups. In athletes, chest pain is often attributed to “chest tightness,” and treatment for bronchospasm is considered. However, the causes of the pain are wide and varied, and the pain is referable to the many organ systems that localize to the thorax. Therefore, when treatment with bronchodilators fails, it becomes important to consider other nonasthmatic causes of the pain. These causes can be organized by system and are explained in this article. Cardiac causes are the most feared and, fortunately, are very rare in the adolescent setting. With a thorough knowledge of etiologies of chest pain, the physician can often make a diagnosis with only a history and a physical exam.

How can we assure procedural competence in pediatric residents in an era of diminishing opportunities? The answer is simulation-based training.

All rights reserved. 10.1016/j.jpeds.2010.02.058 xternal forces have greatly modified the learning environment of pediatric trainees. Restrictions of duty hours decrease the amount of time trainees spend in the clinical environment, reducing exposure to procedures and emergency situations. Consequentially, work compression and increasing complexity of patients’ problems have relegated procedures to a low priority. Patient safety initiatives have led to the creation of rapid response teams designed to take over care in an emergency, further decreasing trainee learning and leadership opportunities. As opportunities become limited, residents are competing with each other for experience. The increasing presence of attending physicians and the use of allied health providers contribute further to decrements in resident autonomy and sense of patient ownership. Fewer available ‘‘practice’’ hours are juxtaposed with increasing demands for documentation of procedural competency (as mandated by both the Pediatric Review Committee and Joint Commission on Accreditation of Healthcare Organizations). The net negative effect cannot be underestimated in pediatrics. Pediatric procedural skills and decision making have unique learning challenges as a child’s anatomy, physiology, and behavior all vary by age. Endotracheal intubation of an infant is different from intubation of a child. Cardiac arrests are rare in pediatrics—life-threatening events more likely begin as unrecognized respiratory emergencies that progress to cardiac arrest. The skill of recognizing an impending event is as important as the skills to manage the emergency. When that emergency occurs, competence in both procedural and critical thinking skills of responders is crucial for optimal outcomes. Nadel in 2000 surveyed pediatric residents and found that 44% of pediatric level-3 residents had never led a resuscitation event. The environment in the 2010s will have further decrements in trainee opportunities, practice, and skill. Together, these influences create what Weinstock, et al have referred to as the ‘‘pediatric training paradox.’’ There is inadequate clinical volume exposure for trainees to ensure optimal patient outcomes. Mastery of the management of medical crises requires teamwork, knowledge and technical skills, and opportunities for deliberate, rather than ‘‘accidental,’’ practice. Deliberate practice affords the learner a task with well-defined goals, a process for feedback, and opportunities for repetition to achieve expertise. Simulation can be the educational vehicle for this process. Simulation recreates events and conditions that may occur in actual patient encounters. Used equipment varies in fidelity. It can be as simple as an ‘‘intubation head’’ or as complex as a human patient simulator (eg, computer-driven mannequin with vital sign changes and physical examination findings) directed by the exercise objectives. The use of simulation is well established in many nonmedical industries, such as the military, the airline industry, and the nuclear power industry. As in medicine, the tasks require high reliability of skills when personnel react to life-threatening emergencies. The cognitive processes and experience of repetition and variation must be developed in a safe arena in which lives are not at stake. Nelson, et al described successful use of simulation to train counselors to deal with emergencies in a camp setting. The camp staff practiced simulations with the automated external defibrillator. Subsequently, a camper was struck by lightening and was successfully resuscitated by staff using the automated external defibrillator. One staff member noted that despite never having managed an actual cardiac arrest, ‘‘I knew what to do, because I’ve already done it a hundred times.’’ The extension of this technique to medicine makes intuitive sense. Simulation is not limited to procedural skills but can also powerfully engage the learner in the cognitive processes necessary to recognize a situation, sort options for intervention, act, and observe the consequences in real time. This far outstrips merely making differential diagnoses. Simulation is a safe, learner-driven environment that allows for the practice of critical thinking, team interaction, leadership, and communication skills. Simulation allows a trainee to enter a real-life situation (eg, in an intensive care unit or the general practice of pediatrics) with practiced skills, instead of the patient encounter or systems crisis being the first opportunity to acquire those skills. Simulation can bridge the experience gap and change chance encounters into deliberate practice. Satisfactory completion of a certain number of curricular block rotations pales as evidence of competence in comparison with cumulative achievement through simulation. The broadest application of simulation in medicine thus far has been in anesthesiology, as pioneered by Gaba. Simulation is nascent in pediatrics. Halamek et al developed a neonatal resuscitation course using both traditional and simulated

Facilitated Peer Group Mentoring: A Case Study of Creating Leadership Skills Among the Associate Program Directors of the APPD

I t is well recognized that academic faculty benefit from mentoring relationships in order to achieve their professional goals, facilitate their scholarly productivity, and make meaningful contributions to their colleagues, trainees, institutions, and departments. Junior faculty are faced with many challenges in developing effective mentoring relationships, including lack of available senior faculty members with proper skill sets or interest in mentorship. Although many mentoring models exist, the most commonly pursued by academic faculty is dyadic mentoring. In traditional dyadic mentoring, one mentor is matched with one mentee (often geographically) based on common interests. Ideally, the dyad participates in a bidirectional relationship. There is a growing body of evidence that other innovative mentoring models, such as facilitated peer group mentoring (FPGM), may be more successful. In FPGM, a senior mentor is assigned to a small group of mentees. The group members serve as peer mentors to each other while working on common interests or projects. The process is facilitated by the senior mentor, who may or may not be a content expert. In this paper, we discuss a case study in which effective, productive mentoring was provided through the use of FPGM. This case study involving associate program directors is illustrative of a successful mentoring experience that resulted in academic productivity and enhanced leadership skills. Associate program directors are involved directly in the

Economic Tough Times: Solutions Found in the Medical Education Continuum

This is a challenging time for all. The country’s economic status is dire, and no one remains untouched. Health care education dollars were already tight. With hospitals and medical schools dealing with massive economic losses, funds for education are disappearing rapidly. Now, more than ever, medical educators need to look at how we spend these funds. Roberts and DeWitt, 1 at a recent workshop, suggested that we can increase the size of the medical education ‘‘pie’’ by pooling resources and capitalizing on the synergy that comes from sharing human resources. In many centers of medical education, medical students, residents, fellows, and practicing physicians are trained in parallel and often competitive environments. One domain’s victory results in fewer resources for the others. However, there are economic advantages and efficiencies in the sharing of resources across the continuum of medical education. Sharing faculty, faculty development programs, space, educational modules, learning technology, simulation centers, standardized patient curricula, evaluation tools, and more will enable medical schools, residency programs, fellowship programs, and continuing medical education to survive and even thrive. Best practices can be shared. Valid and generalizable assessment methods can be developed. Ultimately we can enhance the preparation of physicians to meet our true goal—high-quality health care for all. It is clear that education is a longitudinal process, with learners achieving advancing levels along a continuum well described by the model of skills acquisition of Dreyfus and Dreyfus. 2 Many organizations, in the United States and internationally, have begun to focus on medical education as a continuum. In 1994, Robert G. Petersdorf wrote in the Journal of the Royal Society of Medicine:

Promoting Professionalism in Pediatrics

P rofessionalism is a core competency for residency education and 1 of the 4 key components for maintenance of certification in pediatrics. Yet teaching and assessing professionalism across the spectrum from medical students to residents and fellows to pediatricians in practice can be challenging. Here, we aim to highlight several key concepts that can help educators promote professionalism in pediatrics. One of the most useful definitions of professionalism comes from Stern’s work, Measuring Medical Professionalism: ‘‘Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding, upon which is built the aspiration to, and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.’’ This definition describes professionalism as a behavior to be demonstrated, not an immutable individual trait. Clinical competence is critical to one’s development as a professional, as are excellent communication skills and an understanding of ethical principles. Upon this foundation, professionalism is formed. In 2002, the American Board of Internal Medicine Foundation developed the Physician Charter as part of their Project Professionalism initiative. All of the American Board of Medical Specialties member boards, including the American Board of Pediatrics (ABP), have subsequently adopted the charter. The charter lists 3 fundamental principles—primacy of patient welfare, patient autonomy, and social justice—as well as 10 core professional responsibilities. Some residency programs have begun using the charter in their professionalism curricula and have asked their residents to develop a code of conduct based on these core principles. As educators look at teaching and assessing professionalism across the educational continuum, it is important to think of professionalism as a developmental process. Work by Forsythe and colleages examined the develop-