Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

Exploring Medical Student Experiences With Direct Observation During the Pediatric Clerkship.

PURPOSE: Direct observation (DO) enables assessment of vital competencies, such as clinical skills. Despite national requirement that medical students experience DOs during each clerkship, the frequency, length, quality, and context of these DOs are not well established. This study examines the quality, quantity, and characteristics of DOs obtained during pediatrics clerkships across multiple institutions. METHOD: This multimethod study was performed at 6 U.S.-based institutions from March through October 2022. In the qualitative phase, focus groups and/or semistructured interviews were conducted with third-year medical students at the conclusion of pediatrics clerkships. In the quantitative phase, the authors administered an internally developed instrument after focus group discussions or interviews. Qualitative data were analyzed using thematic analysis, and quantitative data were analyzed using anonymous survey responses. RESULTS: Seventy-three medical students participated in 20 focus groups, and 71 (97.3%) completed the survey. The authors identified 7 themes that were organized into key principles: before, during, and after DO. Most students reported their DOs were conducted primarily by residents (62 [87.3%]) rather than attendings (6 [8.4%]) in inpatient settings. Participants reported daily attending observation of clinical reasoning (38 [53.5%]), communication (39 [54.9%]), and presentation skills (58 [81.7%]). One-third reported they were never observed taking a history by an inpatient attending (23 [32.4%]), and one-quarter reported they were never observed performing a physical exam (18 [25.4%]). CONCLUSIONS: This study revealed that students are not being assessed for performing vital clinical skills in the inpatient setting by attendings as frequently as previously believed. When observers set expectations, create a safe learning environment, and follow up with actionable feedback, medical students perceive the experience as valuable; however, the DO experience is currently suboptimal. Therefore, a high-quality, competency-based clinical education for medical students is necessary to directly drive future patient care by way of a competent physician workforce.

Need for Time and Training: Pediatric Program Directors' Perceptions About Mentorship of Residents.

OBJECTIVE: We aimed to describe pediatric program directors' perceptions of existing mentorship programs in pediatric residencies, to assess whether characteristics used for mentor-mentee assignments impact mentoring outcomes, and to identify barriers to success in mentorship programs. METHODS: With the support of the Association of Pediatric Program Directors (APPD) Research Task Force, we conducted a cross-sectional survey study of all associate pediatric program directors in the United States in March 2022. RESULTS: Nearly half (82 of 197, 41.6%) of programs responded. Most (87.8%) report having a formal mentoring program. Half of programs (51.4%) do not provide training to residents on how to be a mentee, and only slightly more than half (62.5%) provide training to faculty mentors. Most programs (80.6%) do not provide protected time for faculty mentors. There were no meaningful associations with characteristics used for mentorship matches and perceived successful mentorship. Top barriers from the program leadership perspective included faculty and residents lacking time, residents lacking skills to be proactive mentees, and inadequate funding. CONCLUSIONS: While a majority of programs have formal mentorship programs, many do not provide training to mentors or mentees. Barriers to mentorship include a lack of funding and time. National organizations, such as APPD and the Accreditation Council for Graduate Medical Education, have an opportunity to provide guidance and support for protected time, funding, and training for mentors and mentees.

Learner Handoffs Within Clinical Rotations: From the Resident Perspective.

PURPOSE: Competency-based medical education relies on repeated longitudinal assessments of learners. Frequent attending physician transitions within clinical rotations present a significant barrier to the educational continuity required in competency-based medical education. Learner handoffs (LHs), or the transfer of information regarding learners on a team among faculty supervisors, is a potential solution. Although literature is available on educational leader and clinical faculty perspectives on LHs, perspectives of the learners have been less well described. METHOD: This qualitative study used thematic analysis of pediatric resident focus groups from 3 programs of varying size and geographic location from July to December 2021. Two authors independently read the first 3 transcripts to generate a codebook and then coded the remaining transcripts independently to ensure thematic saturation. Emerging themes were discussed and revised until a consensus was achieved. RESULTS: Forty-four pediatric residents from 3 programs participated in 8 focus groups. Themes were identified regarding LHs' positive impact on the (1) learner, (2) clinical practice, and (3) learning environment. Participants described numerous positive benefits to their own development, team functioning, trust, and patient safety. This experience was counterbalanced by risk of bias in the current LH context. Suggestions for the implementation of a structured LH framework were provided, with a focus on the content ( what information), process ( who is involved), and format ( how is it delivered) of LHs. Participants believed that the creation of a structured LH tool may mitigate perceived challenges, including bias and lack of transparency. CONCLUSIONS: Residents recognize potential benefits to learners themselves, their clinical practice, and their learning environment through LHs but express concerns regarding further propagating bias. The development of a structured and learner-centered LH tool could accelerate learner professional development while mitigating perceived challenges. Future research should define essential components of an LH model with input from all key stakeholders.

Opportunities for Mitigating Bias in the Process and Priorities for Pediatric Chief Resident Selection.

OBJECTIVE: To describe the current processes and priorities for pediatric chief resident (CR) selection, to characterize pediatric CR demographics in the past 5 years nationally, and to identify opportunities for addressing bias in the process of pediatric CR selection. METHODS: We used a cross-sectional study design with an anonymous national survey of pediatric program directors (PDs) through a web-based platform in January 2020. RESULTS: A total of 92 of 200 (46%) of PDs responded. About 16% of CR are underrepresented in medicine (UIM) by race/ethnicity. The influential factors most commonly cited in selection were nominations from faculty (84%) and peers (77%), followed by fit with other co-chiefs (68%). Only 17% reported having a specific method to mitigate bias in CR selection, most commonly involving multiple stakeholders in the process. CONCLUSIONS: Current CR selection relies on processes with the potential to introduce bias. Programs have opportunities to address bias in the CR selection process by reevaluating methods vulnerable to bias, including peer/faculty nominations, fit with peers, ITE scores, and assessments through the use of more objective selection tools.

Bolstering diagnostic reasoning skills with adaptive learning.

PURPOSE: Adaptive learning emerges when precise assessment informs delivery of educational materials. This study will demonstrate how data from Human Dx, a case-based e-learning platform, can characterize an individual's diagnostic reasoning skills, and deliver tailored content to improve accuracy. METHODS: Pearson Chi-square analysis was used to assess variability in accuracy across three groups of participants (attendings, residents, and medical students) and three categories of cases (core medical, surgical, and other). Logistic regression analyses were conducted to explore the relationship between solve duration and accuracy. Mean accuracy and duration were calculated for 370 individuals. Repeated measures analysis of variance (ANOVA) were used to assess variability for an individual solver across the three categories. RESULTS: There were significant differences in accuracy across the three groups and the three categories (p < 0.001). Individual solvers have significant variance in accuracy across the three categories. Shorter solve duration predicted higher accuracy. Patterns of performance were identified; four profiles are highlighted to demonstrate potential adaptive learning interventions. CONCLUSIONS: Human Dx can assess diagnostic reasoning skills. When weaknesses are identified, adaptive learning strategies can push content to promote skill development. This has implications for customizing curricular elements to improve the diagnostic skills of healthcare professionals.

Major histocompatibility complex class I molecules modulate embryonic neuritogenesis and neuronal polarization.

We studied cultured hippocampal neurons from embryonic wildtype, major histocompatibility complex class I (MHCI) heavy chain-deficient (K(b)D(b)-/-) and NSE-D(b) (which have elevated neuronal MHCI expression) C57BL/6 mice. K(b)D(b)-/- neurons displayed slower neuritogenesis and establishment of polarity, while NSE-D(b) neurons had faster neurite outgrowth, more primary neurites, and tended to have accelerated polarization. Additional studies with ß2M-/- neurons, exogenous ß2M, and a self-MHCI monomer suggest that free heavy chain cis interactions with other surface molecules can promote neuritogenesis while tripartite MHCI interactions with classical MHCI receptors can inhibit axon outgrowth. Together with the results of others, MHCI appears to differentially modulate neuritogenesis and synaptogenesis.

The endocrine activity of beef cattle wastes: do growth-promoting steroids make a difference?

The primary objective of this study was to compare the endocrine activity of wastes from trenbolone acetate:estradiol (TBA:E)-implanted steers to that of wastes from unimplanted steers. To accomplish this, fathead minnows (Pimephales promelas) were exposed to urine or fecal slurry from TBA:E-implanted or unimplanted steers for 7 days. Following exposures, hepatic vitellogenin (vtg) mRNA expression and secondary sexual characteristics were assessed. Among both males and females, there were no differences in vtg mRNA expression between fish exposed to urine from implanted or unimplanted steers at any of the concentrations tested. Furthermore, concentrations of steroid hormones in the urine of implanted and unimplanted steers were similar. These findings indicate a lack of differences in the endocrine activity of urine from TBA:E-implanted and unimplanted steers. With regard to the fecal slurry exposures, there were no significant differences in vtg mRNA expression among females from any of the groups; however, significant differences in male vtg mRNA expression were detected. Specifically, males exposed to 1600 mg dry feces/L from implanted cattle experienced an 840-fold increase in vtg mRNA expression relative to both unexposed males and males exposed to the corresponding fecal concentration from unimplanted steers. These males also appeared to experience a reduction in male secondary sexual characteristics. These findings suggest that steroids associated with the wastes from TBA:E-implanted steers have both feminizing and demasculinizing effects on male fish. Furthermore, these effects are most likely due to the presence of estrogenic compounds, which were detected in the liquid portion of the fecal slurry from TBA:E-implanted steers, but not in that of unimplanted steers. The findings of this study indicate the presence of endocrine-disrupting compounds in the urine and feces of cattle and suggest that the implant history of cattle alters the endocrine activity of feces, but does not alter the endocrine activity of urine.