Give me a break! Addressing observed structured clinical exam anxiety.

WHAT WAS THE EDUCATIONAL CHALLENGE?: Medical students experience high rates of anxiety; frequent examinations are one contributing source. Students may perceive the observed structured clinical examinations (OSCEs) as particularly stressful. Strategies to reduce anxiety during OSCEs have not been described. WHAT WAS THE SOLUTION?: We sought to implement and evaluate a simple, in-the-moment intervention aimed at reducing students' OSCE-related anxiety by making stress-reducing activities available during break stations during a summative pediatric OSCE. HOW WAS THE SOLUTION IMPLEMENTED?: Three break stations were included in an end-of-rotation, summative OSCE. Students were block-randomized to either control group with standard break stations, or intervention group with stress-reducing activities available in the break room. All participants completed the State-Trait Anxiety Inventory (STAI) before and after the OSCE, and a short questionnaire after OSCE completion. WHAT LESSONS WERE LEARNED THAT ARE RELEVANT TO A WIDER GLOBAL AUDIENCE?: Third-year medical students have high levels of stress before and after OSCEs. More than half of students in the intervention group felt their anxiety improved with activities. While the inclusion of stress-reducing activities in break stations did not impact exam performance, some students subjectively felt their performance improved. If OSCE break stations are logistically required, they can be employed to allow students to briefly relax during a high-stress exam without negatively impacting performance. WHAT ARE THE NEXT STEPS?: Next steps include exploration of opportunities for integration of stress-reducing activities during OSCEs with other learner groups, and identification of other stress-inducing aspects of medical training to provide similar opportunities.

Embracing uncertainty: medical student perceptions of a pediatric bootcamp developed in response to mandated changes during the pandemic.

BACKGROUND: The start of the COVID-19 pandemic led to both shortened clinical rotations and consequent loss of embedded formal teaching time. In response to these learning gaps, a novel, virtual pediatric bootcamp was developed to provide a consolidated 3-week learning opportunity for clinical medical students. Pre-clinical students were encouraged but not required to participate, given the suspension of clinical patient experiences for all undergraduate medical learners and the uncertainty of when clinical rotations would resume. This group of students were particularly challenged with adapting their learning in response to the pandemic while also preparing to apply their pre-clinical knowledge to solve clinical problems. METHODS: A qualitative thematic analysis was used for this study. Ten semi-structured phone interviews were conducted with second-year medical students to explore their experiences and perceptions of the pediatric bootcamp. The six phases of thematic analysis proposed by Braun and Clark guided data analysis. To ensure rigour, the three aspects of rigour-credibility, transferability and confirmability were utilized throughout the project. RESULTS: Qualitative exploration from semi-structured phone interviews of second-year medical students' perceptions and experiences of this new and unanticipated learning experience revealed four main themes: (a) clinical relevance, describing how students were pushed to think about clinical problems in a new way; (b) timing, which explored conflicts related to competing interests, mental preparedness, and the interval between learning and application; (c) teaching strategies, describing how active learning and interaction were facilitated and challenges that arose; and (d) learning resources, highlighting the curated and accessible resources made available to the students, as well as those resources that learners develop for themselves. CONCLUSIONS: A novel three-week online case-based pediatric bootcamp fostered application of knowledge for clinical reasoning at a time when students were transitioning from preclinical to clinical learning. Students were stretched to balance competing priorities, and the bootcamp curated synchronous and asynchronous learner opportunities while allowing them to reflect on their own learning styles and effective virtual learning strategies. While bootcamps are often used to prepare learners for transitions between clinical stages, our findings suggest the bootcamp format can also facilitate transition from preclinical to clinical roles.

Management and outcome of febrile neutropenia in admitted presumed immunocompetent patients with suspected viral illness.

Objectives: Febrile neutropenia (FN) creates concern in paediatrics due to the risk of serious bacterial infections (SBI). Protocols with empiric antibiotics designed for hematology and oncology are often applied in healthy children with FN despite lower rates of SBI in this population. This study quantifies rates of infections in presumed immunocompetent children hospitalized with suspected viral illnesses and FN. Methods: This was a retrospective chart review of healthy children admitted to the Stollery Children's Hospital between 2007 and 2017 with fever, absolute neutrophil counts < 0.5 × 109/L, and viral symptoms. Primary outcomes were the incidence of SBI and bacterial pneumonia. Results: Of 383 encounters reviewed, 96 admissions for 82 patients met inclusion criteria. Eighty-eight encounters (91.7%) were managed with empiric antibiotics. Viruses were identified in 42% of encounters. Three blood cultures were positive for coagulase-negative Staphylococcus and one for Coryneforms, all considered contaminants. There were three urinary tract infections and two pneumonias. Eighty-three per cent of patients had normalization of neutrophil counts, with a median neutropenia duration of 3.2 months. Follow-up diagnoses included chronic benign neutropenia of childhood (N = 17) and three rheumatologic/autoimmune conditions (N = 3). Conclusion: Our results support previous findings of low rates of invasive bacterial infections in healthy children with FN. With an SBI rate of 3.1% and few patients found to have any pathologic etiology for their neutropenia, prospective studies would be valuable to evaluate the need for a practice change regarding antibiotic use in low-risk patients with suspected viral-induced neutropenia.

The paediatrician as a leader: A resident educational intervention for high-value care.

The American College of Physicians defines high-value care (HVC) as health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes. We present a novel 2-hour workshop developed for general paediatric residents designed to promote reflective practice on resource stewardship and raise awareness of costs of medical care in hospitalized children. The workshop impact was assessed quantitatively and qualitatively. Preworkshop, 2-week postworkshop, and 6-month postworkshop electronic surveys were completed by 18 of 43 workshop participants (42% survey participation rate, 100% follow-up in postworkshop surveys) revealing increased knowledge and retention. Thematic analysis performed on 'lessons learned' and 'action plans' provided by participants at the end of the workshop yielded rich data with key findings from learners that included critical thinking about their management and reflecting on nonmonetary costs. Future directions include faculty development and assessment of impact on patient care.

Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study.

INTRODUCTION: Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support. METHODS AND ANALYSIS: This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management. ETHICS AND DISSEMINATION: Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.

A Team-based Learning Approach During Pediatric Clerkship to Promote Clinical Reasoning.

BACKGROUND: Clinical reasoning skills are essential to medical practice. The problem lies in assuming junior medical students with limited experience develop clinical reasoning and decision-making skills passively and solely through clinical exposure. To prepare learners for independent practice and care for future patients, explicit teaching and assessment of clinical reasoning in low-stakes, collaborative learning environments are needed. METHODS: The key-feature question (KFQs) format is an assessment approach that focuses on the reasoning and decision-making aspects of medical problems rather than knowledge recall. This report describes the development, implementation, and evaluation of a team-based learning (TBL) approach using KFQs to foster clinical reasoning in the third-year pediatric clerkship at our institution. RESULTS: Over the first 2 years of implementation (2017-18, 2018-19), 278 students participated in TBL sessions. Mean individual student scores significantly improved in the group setting for both academic years (P < .001). Individual scores were moderately positively correlated with their total summative Objective Structured Clinical Examination score (r[275] = 0.51; P < .001). The correlation between individual score and their multiple-choice question examination was weaker at 0.29 (P < .001) but remained positive. CONCLUSIONS: A TBL session using KFQs to both teach and assess clinical reasoning in clerkship students may help educators identify students with gaps in knowledge and/or reasoning. The next steps include developing and implementing individualized coaching opportunities, and expanding this approach within the undergraduate medical curriculum. Outcome measures to assess clinical reasoning in authentic patient encounters require further research and development.

Miracles in medicine: A narrative inquiry exploring extraordinary events in pediatrics.

Background and Aims: Whether miracles are seen as a source of conflict between healthcare teams and families, a foolish or even harmful belief, or a hindrance to system-wide improvements and scientific inquiry, miracles within medicine have long been questioned. We were interested in the perspectives of pediatricians on miracles and how that has informed their care of patients. We also sought to explore the intersection and relationship between the medical sciences, faith, and how we view miracles. Methods: Using narrative inquiry as a research methodology, we had conversations and explored the experiences of physicians who work directly within pediatric clinical care. We used purposeful sampling by emailing several pediatricians whom we felt might have been interested in the project and may have had experiences with perceived medical miracles. All conversations were conducted over Zoom and recorded. Results: We conducted one to three conversations with each participant. During our analysis, we identified two threads. First, participants described miracles mostly as favorable and fortuitous events that invoked a sense of wonder due to contextual factors such as geography, access to resources, time in history but also previous experiences and the expectations of the clinician. Second, there is a complex dynamic within and between the medical sciences and the faith commitments of clinicians and families, especially when facing life-limiting or end-of-life illness. Conclusions: The stories that our participants told not only informed their past experiences and how they remembered them but also their present and future experiences. Exploring the topic of medical miracles allowed us to better understand the social discourses that shape our perceptions of miracles, death, and the role of the physician. These stories offer us hope and possibility in a time when we as a medical community may have lost our sense of wonder and the ability to notice miracles.

Exploring Virtual Teaching Approaches Among Pediatricians During the SARS-CoV-2 Pandemic: A Virtual Ethnographic Study.

INTRODUCTION: During the SARS-CoV-2 pandemic, Canadian postsecondary institutions were forced to rely on online teaching to comply with physical distancing recommendations. This sole reliance on virtual methods to deliver synchronous teaching sessions in medical education was novel. We found little empirical research examining pediatric educators' experiences. Hence, the objective of our study was to describe and gain a deeper understanding of pediatric educators' perspectives, focusing on the research question, "How is synchronous virtual teaching impacting and transforming teaching experiences of pediatricians during a pandemic?" METHODS: A virtual ethnography was conducted guided by an online collaborative learning theory. This approach used both interviews and online field observations to obtain objective descriptions and subjective understandings of the participants' experiences while teaching virtually. Pediatric educators (clinical and academic faculty) from our institution were recruited using purposeful sampling and invited to participate in individual phone interviews and online teaching observations. Data were recorded and transcribed, and a thematic analysis was conducted. RESULTS: Fifteen frontline pediatric teachers from our large Canadian research-intensive university were recruited. Four main themes, with subthemes, emerged: (1) the love/hate relationship with the virtual shift; (2) self-imposed pressure to increase virtual engagement; (3) looking back, moving forward; (4) accelerated adaptation and enhanced collaboration. CONCLUSION: Pediatricians adopted new delivery methods quickly and found many efficiencies and opportunities in this shift. Continued use of virtual teaching will lead to increased collaboration, enhanced student engagement strategies, and blending the advantages of virtual and face-to-face learning.

International Medical Graduates' perceptions about residency training experience: a qualitative study.

Objectives: To explore International Medical Graduates residents' experiences and perspectives of their residency training program. Methods: This qualitative study was conducted at a large research-intensive University. Purposeful sampling was used to recruit 14 International medical graduates. The residents recruited for this study were at different levels in their training ranging from Postgraduate year one to five. Residents interviewed represented seven unique specialties. Each trainee was interviewed, and the data were recorded and transcribed verbatim. A thematic analysis framework was used to conduct the data analysis, resulting in the development of study themes. Results: Our analysis generated six main themes. These themes were related to costly decisions, unspoken expectations, the stigma associated with being an IMG, fears of being an IMG, the strength and resilience of IMGs, and recommen-dations proposed by IMGs for program improvement. Conclusions: In this study, we wanted to explore international residents' experiences with their programs. The experience of each individual international resident is unique. However, in this study, we were able to provide firsthand perceptions of IMGs from a research-intensive university and identified common themes experienced and perceived by our resi-dents. This study's findings may help educate, reduce stigma, and guide the implementation of effective individu-al and systemic support for these trainees. Which in turn will enhance the overall educational experiences for IMGs trainees. Our study found that themes seem to be recur-ring, hence, an urgency to bring about appropriate chang-es, equitable opportunities, and support for IMGs.

A Scoping Review of Indigenous Health Curricular Content in Graduate Medical Education.

Background: Graduate medical education is refocusing on the reconciliation process with Indigenous peoples and integrating Indigenous healing practices, cultural humility training, and courses on Indigenous health issues in their curricula. Physicians and all health care workers must be able to recognize, respect, and address the distinct health needs of all Indigenous peoples. Objective: The aim of this scoping review was to explore and describe what exists in the current literature on the impact and challenges associated with Indigenous curricula developed for resident physicians. Methods: The search was conducted using 9 bibliographic databases from inception until April 19, 2021. Two reviewers independently screened for inclusion using Covidence. Three reviewers extracted data and all 3 checked for completeness and accuracy. Results: Eleven reports were included. Our included reports consisted of qualitative research (n=2), commentaries (n=1), special articles (n=3), systematic reviews (n=1), innovation reports (n=1), published abstracts (n=1), and program evaluation papers (n=2). Findings are presented by 3 themes: (1) Misunderstandings and cultural bias toward Indigenous people; (2) Increasing community-driven Indigenous partnerships to create a safe environment; and (3) Challenges in implementing Indigenous health curricula. Conclusions: Themes identified related to Indigenous involvement, culturally competent care, common misconceptions about Indigenous peoples, as well as challenges and barriers to implementing Indigenous curricula for residency programs. A collaborative approach involving stakeholders with training in the community is a viable path forward. But comprehensive program evaluation, a source of stable funding, and further research focusing on effective Indigenous curricula for residents are needed.

Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study.

IMPORTANCE: Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE: To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN: We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING: Multicentre study using data from 6 children's hospitals. PARTICIPANTS: Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE: Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES: The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS: Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.

Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years.

OBJECTIVES: No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis. PATIENTS AND METHODS: Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect. RESULTS: There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001). CONCLUSIONS: There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay.

Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study.

INTRODUCTION: Brief Resolved Unexplained Events (BRUEs) are a common presentation among infants. While most of these events are benign and self-limited, guidelines published by the American Academy of Pediatrics inaccurately identify many patients as higher-risk of a serious underlying aetiology (positive predictive value 5%). Recently, new clinical prediction rules have been derived to more accurately stratify patients. This data were however geographically limited to the USA, with no large studies to date assessing the BRUE population in a different healthcare setting. The study's aim is to describe the clinical management and outcomes of infants presenting to Canadian hospitals with BRUEs and to externally validate the BRUE clinical prediction rules in identified cases. METHODS AND ANALYSIS: This is a multicentre retrospective study, conducted within the Canadian Paediatric Inpatient Research Network (PIRN). Infants (<1 year) presenting with a BRUE at one of 11 Canadian paediatric centres between 1 January 2017 and 31 December 2021 will be included. Eligible patients will be identified using diagnostic codes.The primary outcome will be the presence of a serious underlying illness. Secondary outcomes will include BRUE recurrence and length of hospital stay. We will describe the rates of hospital admissions and whether hospitalisation was associated with an earlier diagnosis or treatment. Variation across Canadian hospitals will be assessed using intraclass correlation coefficient. To validate the newly developed clinical prediction rule, measures of goodness of fit will be evaluated. For this validation, a sample size of 1182 is required to provide a power of 80% to detect patients with a serious underlying illness with a significance level of 5%. ETHICS AND DISSEMINATION: Ethics approval has been granted by the UBC Children's and Women's Research Board (H21-02357). The results of this study will be disseminated as peer-reviewed manuscripts and presentations at national and international conferences.

Bilateral leg swelling as the presenting symptom of Löfgren syndrome in a paediatric patient: a rare presentation of a rare paediatric disease.

A 17-year-old previously healthy man presented with a 4-week history of progressive bilateral leg swelling with discomfort and erythema, but no signs of arthritis or erythema nodosum. An incidental finding of a query pulmonary nodule on chest X-ray prompted chest CT for further evaluation, revealing bilateral hilar and mediastinal lymphadenopathy. The patient then underwent endobronchial ultrasound and transbronchial needle aspiration biopsies of mediastinal lymph nodes. Biopsies and bronchoalveolar lavage samples were negative for microbiology, including mycobacterial culture. Pathology demonstrated non-caseating granulomas consistent with a diagnosis of sarcoidosis. Weeks later, he developed arthralgias of the left metacarpophalangeal joints and erythema nodosum and was diagnosed with Löfgren syndrome, a phenomenon rarely described in the paediatric population. This case highlights an approach to lower extremity swelling as well as hilar lymphadenopathy in the paediatric population. In addition, it emphasises the importance of multidisciplinary teamwork for accurate and timely diagnoses.

Experiences of Faculty Members Giving Corrective Feedback to Medical Trainees in a Clinical Setting.

INTRODUCTION: Imperative to medical training is the observation and provision of feedback. In this era of competency-based medical education, feedback is one of the core components of this new model. A better understanding of the medical faculty's attitudes and experiences when providing feedback is essential. Currently, there are limited qualitative studies that have explored attitudes and experiences of faculty members when giving corrective feedback to medical trainees. METHODS: To allow an in-depth exploration of this phenomenon, a hermeneutics phenomenology approach was used, by conducting semistructured interviews with 10 faculty members representing six disciplines and used thematic analysis to create data-driven codes and identify key themes through an iterative consensus-building process. RESULTS: Four themes were identified by the authors: (1) Elements of effective feedback, (2) Faculty members' perception of giving corrective feedback, (3) Challenges as it relates to the assessment culture of the institution, and (4) Providing effective corrective feedback as a mutual process focused on relationship building between learners and preceptors. DISCUSSION: By exploring faculty members' perceptions of providing perceived corrective feedback, we identified actionable recommendations based on the study participants' experiences, expectations, and challenges which could be addressed involving future faculty development with the focus on modifying concepts of feedback and institutional changes that will promote an attitudinal and a cultural shift.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study.

Objectives: An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. Design Setting Participants and Methods: In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Results: Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Conclusions: Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing-choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.