Ventilatory Assistance Before Umbilical Cord Clamping in Extremely Preterm Infants: A Randomized Clinical Trial.

Importance: Providing assisted ventilation during delayed umbilical cord clamping may improve outcomes for extremely preterm infants. Objective: To determine whether assisted ventilation in extremely preterm infants (23 0/7 to 28 6/7 weeks' gestational age [GA]) followed by cord clamping reduces intraventricular hemorrhage (IVH) or early death. Design, Setting, and Participants: This phase 3, 1:1, parallel-stratified randomized clinical trial conducted at 12 perinatal centers across the US and Canada from September 2, 2016, through February 21, 2023, assessed IVH and early death outcomes of extremely preterm infants randomized to receive 120 seconds of assisted ventilation followed by cord clamping vs delayed cord clamping for 30 to 60 seconds with ventilatory assistance afterward. Two analysis cohorts, not breathing well and breathing well, were specified a priori based on assessment of breathing 30 seconds after birth. Intervention: After birth, all infants received stimulation and suctioning if needed. From 30 to 120 seconds, infants randomized to the intervention received continuous positive airway pressure if breathing well or positive-pressure ventilation if not, with cord clamping at 120 seconds. Control infants received 30 to 60 seconds of delayed cord clamping followed by standard resuscitation. Main Outcomes and Measures: The primary outcome was any grade IVH on head ultrasonography or death before day 7. Interpretation by site radiologists was confirmed by independent radiologists, all masked to study group. To estimate the association between study group and outcome, data were analyzed using the stratified Cochran-Mantel-Haenszel test for relative risk (RR), with associations summarized by point estimates and 95% CIs. Results: Of 1110 women who consented to participate, 548 were randomized and delivered infants at GA less than 29 weeks. A total of 570 eligible infants were enrolled (median [IQR] GA, 26.6 [24.9-27.7] weeks; 297 male [52.1%]). Intraventricular hemorrhage or death occurred in 34.9% (97 of 278) of infants in the intervention group and 32.5% (95 of 292) in the control group (adjusted RR, 1.02; 95% CI, 0.81-1.27). In the prespecified not-breathing-well cohort (47.5% [271 of 570]; median [IQR] GA, 26.0 [24.7-27.4] weeks; 152 male [56.1%]), IVH or death occurred in 38.7% (58 of 150) of infants in the intervention group and 43.0% (52 of 121) in the control group (RR, 0.91; 95% CI, 0.68-1.21). There was no evidence of differences in death, severe brain injury, or major morbidities between the intervention and control groups in either breathing cohort. Conclusions and Relevance: This study did not show that providing assisted ventilation before cord clamping in extremely preterm infants reduces IVH or early death. Additional study around the feasibility, safety, and efficacy of assisted ventilation before cord clamping may provide additional insight. Trial Registration: ClinicalTrials.gov Identifier: NCT02742454.

Pediatricians' Career Satisfaction and Wellbeing by Sex Before and During the COVID-19 Pandemic.

OBJECTIVE: To compare pediatrician career satisfaction and wellbeing by sex during the coronavirus disease 2019 pandemic with prepandemic years using longitudinal survey data. METHODS: Data from a cohort study, the American Academy of Pediatrics Pediatrician Life and Career Experience Study, were used to examine career satisfaction and wellbeing from 2012 to 2021 among 2002-2004 and 2009-2011 residency graduates (n = 1760). Mixed effects logistic regression, including key pediatrician characteristics, examined career satisfaction and wellbeing measures for sex (female vs male), pandemic year (2012-2019 vs 2020-2021), and their interaction effect. Adjusted predicted percentage values (PVs) were determined. RESULTS: In total, 73.4% of participants identified as female. Adjusting for key pediatrician characteristics, differences were found by sex for satisfaction and 4 of 5 wellbeing measures, by pandemic year for 2 wellbeing measures, and the interaction of sex and pandemic year for 3 wellbeing measures. Female pediatricians reported higher levels of anxiety, sadness, and work stress, with greater differences during the pandemic. For example, female pediatricians (PV = 22.6, confidence interval [CI] = 21.0-24.3) were more likely than male pediatricians (PV = 14.2, CI = 12.0-16.4) to report anxiety during pre-pandemic years, and the difference between female pediatricians (PV = 29.3, CI = 26.7-32.0) and male pediatricians (PV = 12.4, CI = 9.3-15.5) increased during pandemic years (sex by pandemic year interaction, P < .001). CONCLUSIONS: Compared with male pediatricians, female pediatricians reported worse anxiety, sadness, and stress at work, and the differences were more pronounced during the pandemic.

Examining Early Career Pediatrician Characteristics, Sacrifices, and Satisfaction.

OBJECTIVE: Explore relationships between pediatrician characteristics, sacrifices made for career, and career and life satisfaction. METHODS: Surveys of early career pediatricians (ECPs) who recently graduated residency (2016-18), as part of the AAP Pediatrician Life and Career Experience Study (PLACES) were administered in 2019. Logistic regression analyzed association of pediatrician characteristics with personal sacrifices (a lot vs some or no sacrifices) made for one's career and whether career was worth the sacrifices made to become a physician, and association of characteristics and sacrifices with overall career and life satisfaction. RESULTS: Of 918 ECPs in the cohort, 90% responded to the 2019 survey. Seventy-seven percent agreed their career was worth the sacrifices and 40% reported they made a lot of personal sacrifices for their career. In multivariable analysis, female sex was associated with lower odds of viewing career as worth the sacrifices made [adjusted odds ratio [aOR] 0.45; 95% confidence interval [CI], 0.28-0.71], a higher odds of delaying starting a family [aOR 2.25; CI, 1.32-3.86] and making sacrifices in having children for career [aOR 2.60; CI, 1.48-4.58]. Those in fellowship training also reported making more sacrifices related to having children for their career [aOR 1.73; CI, 1.08-2.78]. ECPs who reported making a lot of sacrifices for their career were less likely to be satisfied with their overall career and life. CONCLUSIONS: Most ECPs believe their sacrifices to become a pediatrician were worth it. Female pediatricians were less likely to feel personal sacrifices were worth it and reported more sacrifices related to having children.

Different Measures and Ways to Categorize Pediatrician Burnout and the Association with Satisfaction.

OBJECTIVE: Compare pediatrician burnout when measured and categorized in different ways to better understand burnout and the association with satisfaction. STUDY DESIGN: We analyzed national survey data from a cohort study of early to midcareer pediatricians. In 2017, participants randomly received 1 of 3 question sets measuring burnout components (emotional exhaustion, depersonalization, and personal accomplishment): group A received the Maslach Burnout Inventory, group B received a previously used measure, and group C received a new severe measure. Repeated measures ANOVA tested differences across burnout categorizations: high emotional exhaustion and high depersonalization and low personal accomplishment; high emotional exhaustion and high depersonalization; and high emotional exhaustion or high depersonalization. Logistic regression tested relationships between burnout profiles (engaged, intermediate, and burnout) and satisfaction. Seventy-one percent of participants completed the survey (1279/1800). RESULTS: Burnout varied depending on measurement (groups A, B, and C) and categorization. For example, for group A, when categorized as high emotional exhaustion, high depersonalization, and low personal accomplishment, burnout was lower (4.8%) than categorized as high emotional exhaustion and depersonalization (15.2%) (P < .001) or categorized as high emotional exhaustion or depersonalization (44.6%) (P < .001). Most participants were satisfied with their career (83.6%). Using burnout profiles, 38.4%-85.1% fell in the engaged profile. For each group, burnout profiles were associated with satisfaction. For example, group A participants in the burnout or intermediate profile were less likely than those engaged to be satisfied with their careers (aOR, 0.08 [95% CI, 0.03-0.24]; and aOR, 0.23 [95% CI, 0.10-0.56], respectively). CONCLUSIONS: The way burnout is measured and categorized affects burnout prevalence and its association with satisfaction. Transparency in methodology used is critical to interpreting results.

Video-Assisted Informed Consent in a Clinical Trial of Resuscitation of Extremely Preterm Infants: Lessons Learned.

OBJECTIVE: Obtaining informed consent for clinical trials is challenging in acute clinical settings. For the VentFirst randomized clinical trial (assisting ventilation during delayed cord clamping for infants <29 weeks' gestation), we created an informational video that sites could choose to use to supplement the standard in-person verbal and written consent. Using a postconsent survey, we sought to describe the impact of the video on patient recruitment, satisfaction with the consent process, and knowledge about the study. STUDY DESIGN: This is a descriptive survey-based substudy. RESULTS: Of the sites participating in the VentFirst trial that obtained institutional review board (IRB) approval to allow use of the video to supplement the standard informed consent process, three elected to participate in the survey substudy. From February 2018 to January 2021, 82 women at these three sites were offered the video and completed the postconsent survey. Overall, 73 of these 82 women (89%) consented to participate in the primary study, 78 (95%) indicated the study was explained to them very well or extremely well, and the range of correct answers on five knowledge questions about the study was 63 to 98%. Forty-six (56%) of the 82 women offered the video chose to watch it. There were no major differences in study participation, satisfaction with the consent process, or knowledge about the study between the women who chose to watch or not watch the video. CONCLUSION: Watching an optional video to supplement the standard informed consent process did not have a major impact on outcomes in this small substudy. The ways in which audiovisual tools might modify the traditional informed consent process deserve further study. KEY POINTS: · Informed consent in acute clinical contexts is difficult.. · Videos offer an alternative communication tool.. · Continued research is necessary to optimize the consent process..

Decline in Pediatric Shelf Examination Performance During COVID-19.

Background Medical student education has been impacted by the ongoing coronavirus 2019 (COVID-19) pandemic. Medical students were removed from clinical settings, and the censuses in pediatric hospitals decreased. While there have been studies starting to evaluate these effects on medical students training in surgical subspecialties, the literature in pediatrics is limited. Objective This study analyzed third-year medical students' National Board of Medical Examiners (NBME) Clinical Science Pediatrics Shelf Exam scores at the conclusion of their core pediatric clerkship. We compared the exam scores before COVID-19 pandemic to those during the pandemic. We hypothesized that the ongoing COVID-19 pandemic would have a negative impact on NBME shelf exam scores and that shelf exam failure rates would increase. Methods Institutional Review Board approval was obtained prior to initiation of this study. We conducted a retrospective review of medical student pediatric shelf exam scores from June 2017 to December 2020 from one large, single institution. We adjusted scores for block schedule timing and standardized them based on national norms published for the year prior. We compared two groups: those who completed their pediatric clerkship experiences before pandemic (predominantly in-person learning) vs. those who completed it during the pandemic (predominantly virtual learning). Groups were compared using chi-square and analysis-of-variance testing. Results We included 991 medical students, 772 before COVID-19 and 219 during COVID-19. Of these, 19 of 772 (2.5%) students failed the exam prior to COVID-19 compared to 19 of 219 (8.7%) during COVID-19 (p < 0.001). Students who completed their pediatric clerkship during COVID-19 were 3.77 times more likely to fail their end-of-clerkship NBME shelf exam (p < 0.001). Conclusions Students who completed their core pediatric clerkship in a predominantly virtual platform during the COVID-19 pandemic were significantly more likely to fail their end-of-clerkship NBME shelf exam. Increased failure rates may suggest issues with acquisition and retainment of pediatric medical knowledge throughout the clerkship, creating knowledge gaps in the foundation of their pediatric experience. Long-term effects of virtual learning platforms will need to be studied further.

Simulation Education for Preterm Infant Delivery Room Management at Community Hospitals.

BACKGROUND: Preterm infants are at risk for hypothermia in the delivery room (DR). Hypothermia and community hospital delivery are factors associated with increased morbidities and mortality in preterm infants. Community hospital providers have less experience with preterm deliveries and thermoregulation methods in the DR. METHODS: Community hospital DR providers in Indiana completed a cognitive test evaluating preterm infant DR management. A simulation-based team assessment was evaluated by using a scoring tool. After debriefing, the simulation performance was repeated and rescored. Afterward, providers completed a cognitive knowledge posttest. Eleven to eighteen months later, sites were revisited with cognitive knowledge and team simulated scenarios reassessed. RESULTS: Twenty-five community hospitals with >400 multidisciplinary providers participated in the initial study visit. Average pre- and posttest scores were 48.8% and 94.1% respectively (P value <.001). Participants performed an average of 22.8 of 36 scoring items during a simulated preterm delivery including 4.4 of 8 thermoregulation related actions. Performance immediately improved in a statistically significant manner during the repeat scenario. When sites were revisited, participants performed an average of 26.7 of 36 scoring items including 6.1 of 8 thermoregulation actions during a simulated preterm delivery a statistically significant (P <.001) improvement from the initial visit. CONCLUSIONS: Simulation education regarding preterm infant DR management improved community providers immediate knowledge and skills and also follow-up performance at ∼1 year. In simulation, providers performed thermoregulation maneuvers more often and efficiently, critical to resuscitation because delays in thermoregulation can significantly adversely affect outcomes.

Development of Validated Checklists to Evaluate Clinical Specialists in Pediatric ECMO Emergencies Using Delphi Method.

Extracorporeal membrane oxygenation (ECMO) is a low-volume, high-risk modality of care. Clinical specialists (CS) who manage ECMO circuit emergencies vary in background and approach to circuit emergencies based on institutional training standards, leading to variation that may impact the quality of care. Validated checklists to assess CS performance are crucial to eliminate disparities and improve efficiency. This study focused on the development and validation of checklists to evaluate the clinical performance of ECMO CS in three ECMO circuit emergencies. A research team with diverse clinical background from our institution developed the first iteration of three ECMO emergency checklists: (1) venous air, (2) arterial air, and (3) oxygenator failure. A modified Delphi technique with a panel of 11 national content experts in ECMO was used to develop content validity evidence. Rating scales from 1 to 7 were used to evaluate each checklist item. The response rate for three rounds of Delphi was 100%. Items with mean score >4 were kept, and new item recommendations were added based on comments from the panel. The venous air, arterial air, and oxygenator failure checklists were revised from 10, 13, and 9 items to 12, 12, and 10 items, respectively. A Cronbach's α of 0.74 during the second round of responses indicated an acceptable degree of agreement. This study demonstrated content validation of three ECMO emergency checklists to assess performance of ECMO CS using a consensus-based Delphi technique. Future validity evidence should be acquired by implementing these checklists in the simulation environments.

Interprofessional Educator Development Course for Simulation.

As interprofessional teams and interprofessional practice become the norm in health care, there is an increasing need for interprofessional educator development to prepare health care students and staff for these new roles. This article describes the development, implementation, and results of an Interprofessional Educator Development Course (IPEDC) for simulation that was created to train clinical educators, practicing professionals, and academic faculty from all health care professions in simulation methodology. The authors, working across disciplines and professions, describe the benefits, limitations, and outcomes of this approach and explain how they met the needs of the involved stakeholders. [J Contin Educ Nurs. 2019;50(10):463-468.].

Gender Differences in Earnings of Early- and Midcareer Pediatricians.

BACKGROUND: The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians. METHODS: We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics. RESULTS: Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less. CONCLUSIONS: Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Gender Discrepancies Related to Pediatrician Work-Life Balance and Household Responsibilities.

BACKGROUND: Physicians must balance career and home responsibilities, yet previous studies on work-life balance are focused primarily on work-based tasks. We examined gender discrepancies and factors related to household responsibilities and work-life balance among pediatricians. METHODS: We used 2015 data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early-career pediatricians. χ2 tests and multivariable logistic regression were used to examine the effects of gender on household responsibilities, satisfaction, and work-life balance attainment. We formally reviewed responses from 2 open-ended questions on work-life balance challenges and strategies for common themes. RESULTS: Seventy-two percent of participants completed the survey (1293 of 1801). Women were more likely than men to report having primary responsibility for 13 of 16 household responsibilities, such as cleaning, cooking, and routine care of children (all P < .001). All gender differences except budget management remained significant when controlling for part-time work status and spouse or partner work status (P < .05). Women were less satisfied with their share of responsibilities relative to others (52% vs 62%; P < .001), and few women and men report being very successful at achieving balance between their job and other life areas (15% vs 19%, respectively; P = .05). Open-ended responses (n = 1145) revealed many barriers to achieving work-life balance. Strategies to increase work-life balance included reducing work hours, outsourcing household-related work, and adjustments to personal responsibilities and relationships. CONCLUSIONS: Female pediatricians spend more time on household responsibilities than male pediatricians, and gender is a key factor associated with work-life balance satisfaction.

Community-based in situ simulation: bringing simulation to the masses.

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.

Attitudes and Experiences of Early and Midcareer Pediatricians With the Maintenance of Certification Process.

OBJECTIVE: Maintenance of certification (MOC) value and relevance have been recent topics of controversy and discussion in medicine. Systematically assessing pediatrician's attitudes and experiences to encourage and inform future modifications is important. METHODS: We surveyed 866 pediatricians in 2014 who graduated from residency 10 to 12 years ago and are part of a larger longitudinal study. Cross-sectional quantitative and qualitative data on understanding, attitudes, barriers, and needs specific to MOC part 2 (self-assessment/continued learning activities) and part 4 (quality improvement projects) were analyzed. McNemar tests compared responses on questions specific to part 2 with those specific to part 4. Multivariable logistic regression considered differences in participants who did and did not have positive part 4 attitudes. RESULTS: A total of 77.8% completed the survey. Comparing part 4 to part 2, there was less understanding of requirements (59.9%, 72.9%, P < .001), more agreement that relevant available activities is a barrier (67.6%, 44.0%, P < .001), stronger agreement that more choices would be helpful (72.8%, 53.8%, P < .001), and less perceived impact on patient care or lifelong learning (12.5%, 47.2%, P < .001). Participants reporting that part 4 improves care were less likely to agree that time to fulfill requirements (adjusted odds ratio = 0.30, 95% confidence interval 0.18-0.51) and relevant available activities (adjusted odds ratio = 0.22, 95% confidence interval 0.13-0.39) were barriers. Qualitative analysis revealed themes including time, cost, and relevance. CONCLUSIONS: Pediatricians expressed significant frustration with the MOC process, poor understanding of requirements, and barriers with the process, especially for part 4. Increasing diplomate education on the process and increasing available and relevant activities may be important to optimize physician's continuous learning.

Neonatal outreach simulation.

Numerous factors contribute to neonatal morbidity and mortality, and inexperienced providers managing crisis situations is one major cause. Simulation-based medical education is an excellent modality to employ in community hospitals to help refine and refresh resuscitation skills of providers who infrequently encounter neonatal emergencies. Mounting evidence suggests that simulation-based education improves patient outcomes. Academic health centers have the potential to improve neonatal outcomes through collaborations with community hospital providers, sharing expertise in neonatal resuscitation and simulation. Community outreach programs using simulation have been successfully initiated in North America. Two examples of programs are described here, including the models for curricular development, required resources, limitations, and benefits. Considerations for initiating outreach simulation programs are discussed. In the future, research demonstrating improved neonatal outcomes using outreach simulation will be important for personnel conducting outreach programs. Neonatal outreach simulation is a promising educational endeavor that may ultimately prove important in decreasing neonatal morbidity and mortality.

Early Career Experiences of Pediatricians Pursuing or Not Pursuing Fellowship Training.

BACKGROUND AND OBJECTIVES: Choosing career paths can be difficult decisions for residents contemplating fellowship training. This study compares the experiences of early career pediatricians who did and did not pursue fellowships. METHODS: We analyzed national, weighted data from pediatricians 8 to 10 years after residency (n = 842). Work environment, work-life balance, and satisfaction were compared for pediatricians who had pursued fellowship training (fellowship trained) and those who did not pursue fellowship training (generalist trained). Logistic and linear regression examined the independent effects of fellowship training while controlling for demographic differences. RESULTS: A total of 39% of the pediatricians (328/842) pursued fellowship training. The fellowship-trained group was less likely than the generalist-trained group to spend time in direct patient care and more likely to report learning opportunities in their work environment. This group was also more likely to report an income of ≥$150,000, although no difference was found when only full-time pediatricians were examined. Generalist-trained pediatricians were more likely to work <50 hours per week, have flexibility with their schedules, and be satisfied with time spent with their own children. Pediatricians in both the fellowship-trained and generalist-trained groups generally found their work to be rewarding and were satisfied with their lives. CONCLUSIONS: Although residents need to consider important life and career differences when contemplating fellowship training and general care, pediatricians in both groups can achieve overall life and career satisfaction.