Bronchiolitis Simulation Module in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum.

Introduction: Acute bronchiolitis is a viral infection infecting 90% of children under the age of 2 years, with approximately 200,000 deaths per year. The current standard of care remains largely respiratory support and prevention. Therefore, understanding how to assess and escalate respiratory supportive care is paramount for health care providers taking care of children. Methods: We used a high-fidelity simulator to simulate an infant with progressing respiratory distress in the setting of acute bronchiolitis. The participants were pediatric clerkship medical students during their preclerkship educational exercises (PRECEDE). The students were asked to evaluate and treat the simulated patient. After debriefing, the students repeated the simulation. We assessed both performances via a weighted checklist specifically developed for this case to measure team performance. Students also completed an overall course evaluation. Results: Ninety out of 121 pediatric clerkship students were enrolled. Performance improved from 57% to 86% ( p < .05). Donning appropriate personal protection equipment was the most missed item both pre- and postdebriefing. Overall, the course was well liked and received. Participants requested more simulation opportunities within PRECEDE as well as a summary document to reinforce learning. Discussion: Pediatric clerkship students improved their performance managing progressing respiratory distress due to acute bronchiolitis via a performance-based assessment tool with sound validity evidence. Improvements going forward include improving faculty diversity and offering more simulation opportunities.

Evaluation of the implementation of an online psychiatric nurse practitioner program for primary care nurse practitioners: Use of a Participatory Evidence-Informed (PEPPA-Plus) framework.

To address a growing need for primary care nurse practitioners to provide mental health care, grant support was obtained to create an accelerated online post-master's psychiatric-mental health nurse practitioner (PMHNP) program. A participatory evidence-informed framework (PEPPA-Plus) was used to 1) evaluate the program structures and processes from the perspectives of program graduates, and within this context, to evaluate outcomes following graduation, and 2) to evaluate the impact of the program through the implementation of the dual nurse practitioner role. Approximately half (56%) of the graduates completed a 40-item web-based survey. Ninety-nine percent of those who had taken the PMHNP exam were certified as PMHNPs, 99% were dually certified as primary care NPs, 86% reported that their scope of practice had changed to include the delivery of more mental health care services, and 27% were providing both mental and physical health care in integrated care settings. The vast majority (90%) reported a moderate to very high level of confidence in their PMHNP competency, 60% were teaching psychiatric-mental health nursing as preceptors, educators, or new program directors and 29% were providing care in communities with <50,000 residents. Over half of the graduates were committed to staying in their current practice position for at least the next five years. These findings demonstrate the success of the online program in producing graduates who utilize dual NP competencies in practice, at least 25% of whom are treating populations in non-urban settings, in integrated care settings, and treating populations with high social and environmental risk factors.

Recognizing Reflection: Computer-Assisted Analysis of First Year Medical Students' Reflective Writing.

BACKGROUND: Reflective writing is used throughout medical education to help students navigate their transformation into medical professionals. Assessment of reflective writing, however, is challenging; each available methodology of assessment has distinct advantages and disadvantages. We tested if combining two independent assessment mechanisms-a faculty-designed rubric and Academic Writing Analytics (AWA), an automated technique-could be used together to form a more robust form of evaluation. METHODS: We obtained reflective essays written by first year medical students as part of a clinical skills course. Faculty scored essays using a rubric designed to evaluate Integration, Depth, and Writing. The same essays were subjected to AWA analysis, which counted the number of reflective phrases indicative of Context, Challenge, or Change. RESULTS: Faculty scored the essays uniformly high, indicating that most students met the standard for reflection as described by the rubric. AWA identified over 1400 instances of reflective behavior within the essays, and there was significant variability in how often different types of reflective phrases were used by individual students. CONCLUSIONS: While data from faculty assessment or AWA alone is sufficient to evaluate reflective essays, combining these methods offer a richer and more valuable understanding of the student's reflection.

Otitis Media Module in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum.

Introduction: The Johns Hopkins Pediatrics Clerkship developed the PRECEDE (preclerkship educational exercises) curriculum with the primary goal of offering students formative instruction in essential pediatric clinical skills to prepare them for their clerkship. PRECEDE sessions occur at the beginning of each basic clerkship for new clinical clerkship students. The otitis media module is one in a series of modules presented in the curriculum and consists of a lecture and four short skills-development stations, each with a faculty facilitator. Methods: This 2-hour module began with a 1-hour didactic overview of otitis media. Medical students were divided into three groups. One group learned about writing prescriptions via two otitis media clinical vignettes. Another group explored visualization and diagnosis of otitis media via video. The last student group was subdivided and learned proper techniques for positioning and restraining pediatric patients during otoscopic exams and the psychomotor skills for performing otoscopic examinations, including pneumatic otoscopy. Student groups rotated through all four activity stations. Students were guided through discussion to develop interpretation, diagnostic, and treatment skills for acute otitis media. Results: Between 2010 and 2012, 254 third- and fourth-year medical students participated in this module. When asked to evaluate overall quality, 86% of learners rated the module as excellent, and 14% rated it as good. Discussion: By establishing these important skills, students may be better equipped to develop appropriate otitis media assessments, diagnoses, and care plans for patients and to use otitis media as a platform for broad education in other essential pediatric skills.

The Process of Developing an Assessment Checklist for Simulated Infant Respiratory Distress Using a Modified Delphi Method: A Mixed Methods Study.

Introduction Assessing clinical performance, such as managing respiratory distress, in clinical trainees is challenging yet important. Our objective was to describe and evaluate an integrative and iterative approach to developing a checklist measuring simulated clinical performance for infant respiratory distress. Methods We implemented a five-step modified Delphi process with an embedded qualitative component. An implementation period occurred followed by a second qualitative data collection. Validity evidence was collected throughout the process. Results A 19-item assessment checklist was developed for managing infant respiratory distress by medical student learners in a simulation-based setting. The iterative process provided content validity while the qualitative data provided response process validity. Cohen kappa was 0.82 indicating strong rater agreement. The assessment checklist was found to be easy to use and measure what was intended. Conclusion We developed an accurate and reliable assessment checklist for medical student learners in a simulation-based learning setting with high interrater reliability and validity evidence. Given its ease of use, we encourage medical educators and researchers to utilize this method to develop and implement assessment checklists for their interventions.

Relationship-Centered Advising in a Medical School Learning Community.

BACKGROUND: Medical schools are required to have formal advising structures; however, there are limited data on how to optimally meet that mandate. Learning communities (LC), with their emphasis on longitudinal relationships, offer a unique scaffold for advising. PROGRAM DESCRIPTION: The Johns Hopkins School of Medicine (JHSOM) LC focuses on curricular and extracurricular longitudinal connections between students and advisors. A core component of the LC is a relationship-centered advising (RCA) model drawing from best practices in physician-patient relationships, life coaching, and social contract theories. The key elements of the model include dyadic and small group advising, while the LC structure allows for faculty development in these domains. Relationship-centered advising approaches the collaborative advising work between students and advisors through explicit valuing of personal experiences, mutual respect, and earned trust. Framing the advising relationship in this way allows it to grow with the student along their medical school journey. PROGRAM EVALUATION & RESULTS: Student and faculty satisfaction with this model is high. Data from annual, anonymous student evaluations consistently indicate high degree of trust in and satisfaction from these relationships. DISCUSSION: Relationship-centered advising aims to create a relationally anchored platform on which students can develop their personal and professional identities. This LC-based advising model is adaptable across schools regardless of structure and resources.

Variability in Institutional Board Review for a Multisite Assessment of Resident Professionalism.

Residents serve as both trainees and employees and can be considered potentially vulnerable research participants. This can lead to variation in the institutional review board (IRB) review. We studied sites participating in the Assessment of Professional Behaviors Study sponsored by the National Board of Medical Examiners (2009-2011). Of the 19 sites, all but one were university affiliated. IRB review varied; 2/19 did not submit to a local IRB, 4/17 (23%) were exempt, 11/17 (65%) were expedited, and 2/17 (12%) required full Board review; 12/17 (71%) required written informed consent. The interval from submission to approval was 1 to 2 months (8/17); the range was 1 to 7 months. Although most stated there were no major barriers to approval, the most common concern was resident coercion and loss of confidentiality. Local IRB review of this educational research study varied.

Caregivers' Priorities and Observed Outcomes of Attention-Deficit Hyperactivity Disorder Medication for Their Children.

OBJECTIVE: To document variability among caregivers' priorities when considering medication to treat their Children's attention-deficit hyperactivity disorder (ADHD) and explore associations between these priorities and medication-related improvements. METHODS: Caregivers of children, ages 4 to 14 years, diagnosed with ADHD were recruited from outpatient clinics and support groups across Maryland. A survey gathered data on caregiver-reported concerns when considering ADHD medication, demographic characteristics, and observed and desired improvements in their child's ADHD. A validated Best-Worst Scaling instrument assessed priorities among 16 concerns when considering ADHD medication. Latent class analysis identified subgroups with similar ADHD medication concerns. Differences in self-reported medication-related improvements were examined across subgroups. RESULTS: The 184 participants (mean = 42 yrs) were primarily the biological mother, 68% white and 25% black. Their children were mostly male (73%) and using medication (81%). Overall, the most important ADHD medication concerns were the child becoming a successful adult (p < 0.0001), school behavior improvements (p < 0.0001), and better grades (p < 0.0001). Others thinking badly of the child was a significantly less important concern (p < 0.0001). Three subgroups were identified: short-term outcomes-oriented group (39%), long-term outcomes-oriented group (37%), and side effects/safety-oriented group (27%). Relative to the other 2 groups, a smaller proportion of the side effects/safety-oriented group desired these improvements (p < 0.2618). CONCLUSION: Most caregivers prioritize short- and long-term outcomes when considering ADHD medication. However, those most concerned with long- or short-term outcomes tended to desire additional improvements in their child's ADHD.

Growth Module in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum.

Introduction: The Johns Hopkins Pediatrics Clerkship developed this growth module as part of the PRECEDE (preclerkship educational exercises) curriculum, with the primary goal of providing students with experiential, explicit, and standardized instruction in essential pediatric clinical skills to better prepare them to utilize these skills during their clerkship. Methods: This 2-hour growth module begins with a 45-minute didactic overview of growth, including discussion of normal growth, normal variants of growth, and disorders that affect growth, and contains interactive elements to engage the students. Students then divide into groups of four to six, each with a faculty facilitator to work through three cases in a guided discussion to explore specific aspects of growth that may be encountered in a pediatric evaluation. Results: In a survey of 238 students, 97-100% agreed or strongly agreed with eight positive assessments of the module. Likewise, 79% of students rated the module as excellent, the remainder rating the module as good. Discussion: From the perspectives of students and instructors, the implementation of this new module was very successful in its delivery of educational content. These cases were designed to give the students experience in plotting growth parameters against normative data and to gain familiarity with pediatric growth curves in order to identify growth abnormalities. The cases also aimed to reinforce the importance of using growth data in pediatric patients in order to both generate a differential diagnosis for a growth disorder and to modify a differential diagnosis generated by a chief complaint based on growth data.

On-site Mental Health Professionals and Pediatric Residents in Continuity Clinic.

The objective of the study was to examine differences in pediatric resident perceptions and practices related to child mental health conditions in continuity clinic settings with versus without on-site mental health professionals (MHPs). A 20-item questionnaire, based on the American Academy of Pediatrics Periodic Survey Number 59, was administered to pediatric residents in a medium-sized program from 2008 to 2011. Of 130 residents surveyed, compared with their peers, those practicing with the on-site MHPs were more likely to report mental health services as very available in their clinic (odds ratio [OR] = 39.7; P = .000). Residents with on-site MHPs inquired more frequently about attention-deficit/hyperactivity disorder (ADHD; OR = 2.96; P = .029) and referred more frequently for ADHD (OR = 3.68; P = .006), depression (OR = 2.82; P = .030), and behavioral problems (OR = 3.04; P = .012). On-site MHPs in continuity clinics offer great potential to improve resident education and patient care. Additional research is necessary to further understand their impact.

Caregiver Treatment Preferences for Children with a New Versus Existing Attention-Deficit/Hyperactivity Disorder Diagnosis.

OBJECTIVES: Parental experiences with managing their child's attention-deficit/hyperactivity disorder (ADHD) can influence priorities for treatment. This study aimed to identify the ADHD management options caregivers most prefer and to determine if preferences differ by time since initial ADHD diagnosis. METHODS: Primary caregivers (n = 184) of a child aged 4-14 years old in care for ADHD were recruited from January 2013 through March 2015 from community-based pediatric and mental health clinics and family support organizations across the state of Maryland. Participants completed a survey that included child/family demographics, child clinical treatment, and a Best-Worst Scaling (BWS) experiment to elicit ADHD management preferences. The BWS comprised 18 ADHD management profiles showing seven treatment attributes, where the best and worst attribute levels were selected from each profile. A conditional logit model using effect-coded variables was used to estimate preference weights stratified by time since ADHD diagnosis. RESULTS: Participants were primarily the mother (84%) and had a college or postgraduate education (76%) with 75% of the children on stimulant medications. One-on-one caregiver behavior training, medication use seven days a week, therapy in a clinic, and an individualized education program were most preferred for managing ADHD. Aside from caregiver training and monthly out-of-pocket costs, caregivers of children diagnosed with ADHD for less than two years prioritized medication use lower than other care management attributes and caregivers of children diagnosed with ADHD for two or more years preferred school accommodations, medication, and provider specialty. CONCLUSIONS: Preferences for ADHD treatment differ based on the duration of the child's ADHD. Acknowledging that preferences change over the course of care could facilitate patient/family-centered care planning across a range of resources and a multidisciplinary team of professionals.

Maternal Experiences in a Parenting Group Delivered in an Urban General Pediatric Clinic.

Untreated perinatal mood and anxiety disorders can result in impaired maternal-infant interactions. Pediatricians have a unique opportunity to identify and support mothers with mood and anxiety disorders. A parenting intervention, Circle of Security, was delivered in a pediatric clinic targeting women with mood and anxiety disorders. A qualitative assessment of the program's acceptability, participant engagement, and general experiences was conducted. Data collection included medical record abstraction, semistructured psychiatric diagnostic interviews, and semistructured questionnaires. Findings indicate Circle of Security is a feasible and practical approach to providing parenting support to women of young children with mood and anxiety disorders in the pediatric medical home. Additional larger studies will be helpful in tracking outcomes of participating women and infants and in further aiding pediatricians in teaching about attachment and emotions, empowering mothers to talk about their struggles, and ensuring support for mothers in reflecting on their emotions and experiences that affect parenting.

A Latent Class Analysis to Identify Variation in Caregivers' Preferences for their Child's Attention-Deficit/Hyperactivity Disorder Treatment: Do Stated Preferences Match Current Treatment?

OBJECTIVES: To investigate variation in caregiver preferences for their child's attention-deficit/hyperactivity disorder (ADHD) care and to determine if their stated preferences align with current care management. METHODS: Caregivers of a child aged 4-14 years and in care for ADHD were recruited from pediatric outpatient clinics and advocacy groups across the state of Maryland. Participants completed a survey collecting demographics, the child's treatment, and caregiver preferences-elicited using a best-worst scaling experiment (case 2). Latent class analysis was used to identify distinct preference segments and bivariate analyses were used to compare the association between segment membership with what the child was currently receiving for their ADHD. RESULTS: Participants (n = 184) were predominantly White (68%) and the child's mother (84%). Most children had ADHD for 2 or more years (79%). Caregiver preferences were distinguished by two segments: continuous medication (36%) and minimal medication (64%). The two groups had very different preferences for when medication was administered (p < 0.001), but they had similar preferences for provider-oriented and non-medication interventions (p > 0.05 for the caregiver behavior training, provider communication, provider specialty, and out-of-pocket costs). One third of the sample did not receive the preferred individualized education program and 42% of the minimal medication group reported using medication 7 days a week all year round. CONCLUSIONS: Although behavior management training and school accommodations aspects of an ADHD care plan are more important to caregivers than evidence-based medication, fewer families had access to educational accommodations. Further research is needed to clarify how stated preferences for care align with treatments used in actual practice settings.

Interpretation of Data Workshop in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum.

INTRODUCTION: The PRECEDE (preclerkship educational exercises) curriculum was developed by the Johns Hopkins Pediatrics Clerkship with the primary goal of providing students with experiential, explicit, and standardized instruction in essential pediatric clinical skills to better prepare them for their clerkships. This data interpretation workshop is one of a series of modules within the PRECEDE curriculum presented just prior to the clerkship. METHODS: This 2-hour workshop divides medical students into small groups of four to six students, each group with a faculty facilitator. Three clinical vignettes are presented to the student groups. For each vignette, students participate in a guided discussion to develop an interpretation and understanding of what is often misinterpreted pediatric information, such as developmental milestones, vital signs, and laboratory values. RESULTS: From the perspectives of students and instructors, the implementation of this new module was very successful in terms of its delivery of educational content and its organizational structure. Of 229 students who participated in the session and completed surveys, 77% strongly agreed the session was educationally valuable. DISCUSSION: By establishing important basic skills of correct pediatric data interpretation, students may be better equipped to develop appropriate differential diagnoses, assessments, and plans of care for patients.

Introductory Learning of Inclusive Sexual History Taking: An E-Lecture, Standardized Patient Case, and Facilitated Debrief.

INTRODUCTION: This student-driven curriculum intervention, implemented with first-year medical students, was guided by the Association of American Medical Colleges' standards for medical education on health care for sexual and gender minorities. Its goals are to describe the spectrum of sexual orientation and gender identity and sensitively and effectively elicit relevant information from patients about their sexual orientation and gender identity through inclusive sexual history taking. METHODS: Developed through student-faculty collaboration, this three-part module includes a 14-minute e-lecture on taking an inclusive sexual history, a 35-minute formative standardized patient encounter in which students take a sexual history and receive feedback, and a 20-minute facilitated group debrief on the standardized patient activity. RESULTS: Students completed a postmodule evaluation anonymously; the majority of respondents (92%) agreed that they felt more prepared to take a sexual history inclusive of sexual and gender minority patients. Most were more comfortable discussing sexual orientation (91%) and gender identity (83%) with patients after the module. Content analysis revealed an improved confidence in creating a safe space for sexual and gender minority patients and an increased awareness of biases about sexual and gender minority patients. DISCUSSION: This curriculum serves as an early foundation for students to understand sexual and gender minority identities and develop confidence in their inclusive sexual history taking skills before they provide care for patients. In addition, the student-driven curriculum development process used can serve as a template for students at other institutions hoping to collaborate with faculty to develop comprehensive sexual and gender minority curricula.

A best-worst scaling experiment to prioritize caregiver concerns about ADHD medication for children.

OBJECTIVE: The objective of this feasibility study was to develop and pilot an instrument to elicit caregivers' priorities when initiating attention-deficit hyperactivity disorder (ADHD) medication for their child. METHODS: A best-worst scaling experiment was used to rank competing priorities when initiating ADHD medicine. Forty-six participants were recruited for a two-phase study involving survey development (phase 1, N=21) and the survey pilot (phase 2, N=25). Best-worst scores and 95% confidence intervals indicating the relative importance of 16 concerns were determined, and t tests were used to determine the scores' significance. RESULTS: The significance of best-worst scores for most concerns indicated that the choices were purposeful. Concerns about helping the child become a successful adult, having a doctor who addresses caregivers' concerns, and improving school behavior were ranked highest. CONCLUSIONS: The best-worst scaling method can elicit priorities for children's mental health treatment. Future work using this method will guide family-centered care.

Do Parents Expect Pediatricians to Pay Attention to Behavioral Health?

BACKGROUND AND OBJECTIVE: This study is a qualitative analysis examining caregivers' expectations for pediatricians with regard to behavioral health care. METHODS: Fifty-five parents/caregivers of children seen in an urban primary care clinic participated in semistructured interviews. Participants were parents or guardians of children between the ages of 2 and 17 years, referred from the pediatric clinic to the mental health center. Interviews were analyzed using grounded theory methods. RESULTS: Pertinent themes were the following: expected range of care, components of an effective primary care provider (PCP) relationship, action of the PCP, and parent reaction to PCP intervention. Forty-seven percent of caregivers saw the PCP role as strictly for physical health care; 53% expected the PCP to have a role in both physical and behavioral health. Responses were overwhelmingly positive from caregivers when the PCP asked about or conducted a behavioral health intervention. CONCLUSION: Caregivers did not consistently expect but responded positively to PCPs engaging around behavioral health concerns.

Using Best-Worst Scaling to Measure Caregiver Preferences for Managing their Child's ADHD: A Pilot Study.

BACKGROUND: Management of attention-deficit/hyperactivity disorder (ADHD) is a trade-off between caregivers' concerns about the benefits versus the risks of evidence-based treatment. Few studies have used choice-based methods to assess what treatment attributes matter most to caregivers. OBJECTIVE: The aim was to develop and to pilot an instrument to elicit caregivers' preferences for evidence-based management of their child's ADHD. METHODS: Mixed methods were used to develop a Best-Worst Scaling (BWS) instrument, and quantitative methods were used to pilot the instrument. Primary caregivers of children with ADHD from two community organizations were recruited for the development (n = 21) and pilot (n = 37) phase. The instrument was a BWS case 2, where 18 management profiles are presented one at a time, with respondents indicating the one best and one worst feature of each profile. Profiles were developed using a main effects orthogonal array. The mean of best-minus-worse scores was estimated, and attribute importance was based on the sum of maximum minus minimum scores for each attribute. Feasibility of eliciting stated preferences was evaluated with t tests and 95 % confidence intervals. RESULTS: Seven attributes (medication, therapy, school, caregiver training, provider specialty, provider communication, and out-of-pocket costs) with three levels each were identified. All mean scores were significant except for pediatrician management of the child's ADHD (p = 0.089). Caregiver training had the highest relative importance, followed by medication and provider communication. CONCLUSIONS: The BWS instrument was a relatively simple measure, caregivers completed it independently, and it distinguished the relative importance of different attributes in managing a child's ADHD.