The nature of excellent clinicians at an academic health science center: a qualitative study.

PURPOSE: To understand the nature of excellent clinicians at an academic health science center by exploring how and why excellent clinicians achieve high performance. METHOD: From 2008 to 2010, the authors conducted a qualitative study using a grounded theory approach. Members of the Clinical Advisory Committee in the Department of Pediatrics at the University of Toronto nominated peers whom they saw as excellent clinicians. The authors then conducted in-depth interviews with the most frequently nominated clinicians. They audio-recorded and transcribed the interviews and coded the transcripts to identify emergent themes. RESULTS: From interviews with 13 peer-nominated, excellent clinicians, a model emerged. Dominant themes fell into three categories: (1) core philosophy, (2) deliberate activities, and (3) everyday practice. Excellent clinicians are driven by a core philosophy defined by high intrinsic motivation and passion for patient care and humility. They refine their clinical skills through two deliberate activities-reflective clinical practice and scholarship. Their high performance in everyday practice is characterized by clinical skills and cognitive ability, people skills, engagement, and adaptability. CONCLUSIONS: A rich theory emerged explaining how excellent clinicians, driven by a core philosophy and engaged in deliberate activities, achieve high performance in everyday practice. This theory of the nature of excellent clinicians provides a holistic perspective of individual performance, informs medical education, supports faculty career development, and promotes clinical excellence in the culture of academic medicine.

Decision-making around gastrostomy-feeding in children with neurologic disabilities.

OBJECTIVE: The objective of this study was to understand the decision-making experiences, perspectives, and beliefs of parents of children with a neurologic disability around gastrostomy tube-feeding. DESIGN AND METHODS: We conducted a systematic review of qualitative studies to explore the experiences of parents of children with a neurologic disability around gastrostomy-feeding. We searched 5 electronic databases from inception to July 2010. Two authors independently selected articles and extracted data. Concepts and themes relevant to decision-making were constructed by using thematic analysis. RESULTS: Eleven studies were selected in which experiences relevant to decision-making were reported. The decision-making process was characterized by decisional conflict. Concepts important to understanding conflict were categorized under 3 themes: values; context; and process. The value and meaning of feeding by mouth and, in contrast, with a gastrostomy tube was the dominant theme that led to internal distress for parents in decision. Feeding by mouth was seen as an enjoyable activity, an important social process, but also a struggle. Gastrostomy-feeding represented a loss of normality, a sign of disability, and a disruption of maternal nurturing and bonding. Context (child and family characteristics) and process (information sharing and support) modified the decision-making experience. CONCLUSIONS: Values associated with gastrostomy-feeding and feeding by mouth, the context of child and family, and the process of decision-making facilitated by the health care system shape parental experiences and decisional conflict. This framework will help guide interventions, such as patient decision aids, that are aimed at improving parental decision-making.

Hospital-based comprehensive care programs for children with special health care needs: a systematic review.

OBJECTIVE: To examine the effectiveness of hospital-based comprehensive care programs in improving the quality of care for children with special health care needs. DATA SOURCES: A systematic review was conducted using Ovid MEDLINE, CINAHL, EMBASE, PsycINFO, Sociological Abstracts SocioFile, and Web of Science. STUDY SELECTION: Evaluations of comprehensive care programs for categorical (those with single disease) and noncategorical groups of children with special health care needs were included. Selected articles were reviewed independently by 2 raters. DATA EXTRACTION: Models of care focused on comprehensive care based at least partially in a hospital setting. The main outcome measures were the proportions of studies demonstrating improvement in the Institute of Medicine's quality-of-care domains (effectiveness of care, efficiency of care, patient or family centeredness, patient safety, timeliness of care, and equity of care). DATA SYNTHESIS: Thirty-three unique programs were included, 13 (39%) of which were randomized controlled trials. Improved outcomes most commonly reported were efficiency of care (64% [49 of 76 outcomes]), effectiveness of care (60% [57 of 95 outcomes]), and patient or family centeredness (53% [10 of 19 outcomes). Outcomes less commonly evaluated were patient safety (9% [3 of 33 programs]), timeliness of care (6% [2 of 33 programs]), and equity of care (0%). Randomized controlled trials occurred more frequently in studies evaluating categorical vs noncategorical disease populations (11 of 17 [65%] vs 2 of 16 [17%], P = .008). CONCLUSIONS: Although positive, the evidence supporting comprehensive hospital-based programs for children with special health care needs is restricted primarily to nonexperimental studies of children with categorical diseases and is limited by inadequate outcome measures. Additional high-quality evidence with appropriate comparative groups and broad outcomes is necessary to justify continued development and growth of programs for broad groups of children with special health care needs.

Early parental adjustment and bereavement after childhood cancer death.

This study comprehensively explored parental bereavement and adjustment at 6 months post-loss due to childhood cancer. Interviews were conducted with 18 mothers and 13 fathers. Interviews were transcribed verbatim and analyzed based on qualitative methodology. A model describing early parental bereavement and adaptation emerged with 3 domains: (1) Perception of the Child, describing bereavement and adjustment prior to and after the loss; (2) Perception of Others, including relationships with partners, surviving children, and their social network; and (3) Perception of the World, exploring parents' perceived meanings of the experience in the context of their worldview. Domains are illustrated by quotes. Profiles of parental bereavement emerged.

Bereaved parents' perspectives on their needs.

OBJECTIVE: The loss of a child can be traumatic for parents, given the profound bond established with the deceased child. Parental bereavement and the need for bereavement services are not well understood. This study examined parental perspectives regarding bereavement services from a pediatric oncology treating center. METHODS: A 2-h focus group of seven parents, audiotaped and transcribed verbatim, was conducted by two facilitators using open-ended questions to generate discussion regarding their views of what services were or would be helpful during early bereavement. RESULTS: Parents perceived flexible and continuous bereavement services from the treating hospital as a necessary transition to community services. Talking to other parents with similar experiences and maintaining contact with staff at the treating hospital were considered critical in their healing after the loss. SIGNIFICANCE OF RESULTS: Transitional multimodality bereavement services offered by the treating hospital will improve the quality of life of bereaved families.

Patterns of parental bereavement following the loss of a child and related factors.

This study investigated the patterns of parental bereavement in 20 parents who have lost a child to cancer, congenital heart disease, meningitis, or drowning in the last 19 months, using semi-structured interviews and standardized questionnaires of depression and grief. Qualitative content analysis of interviews identified three bereavement patterns: The majority of parents (65%) presented uncomplicated, Integrated Grief five mothers were Consumed by Grief and one mother and one father expressed Minimal Grief. Quotes from parents exemplified these patterns. Parental gender, symptoms of depression, and pre-death relationship between parents and their deceased child differentially related to these patterns. Having surviving children, social support, and being active appeared to help to integrate grief into daily life. These findings illustrate differential patterns of parental bereavement and related factors, information that has important implications for identifying at-risk parents for complicated bereavement.

The prevalence of overweight and obesity in pediatric survivors of cancer.

OBJECTIVE: To compare the prevalence of overweight in a cohort of pediatric survivors of cancer with that in the general population. STUDY DESIGN: We reviewed the charts of 441 cancer survivors followed at a Canadian tertiary care pediatric hospital and calculated their most recent body mass index. We compared this cohort with population data generated from the Canadian Community Health Survey. RESULTS: At a median age of 14.7 years (range, 3.4 to 19.5 years) and a median time from diagnosis of 9.7 years (range, 3.4 to 19.2 years), 140 of 441 patients (31.7%) were overweight or obese. Only 12 of the 441 patients (2.7%) were underweight. Males age 6 to 11 years (odds ratio [OR] = 2.29; 95% confidence interval [CI] = 1.36 to 3.86; P < .001) and male survivors of acute lymphoblastic leukemia (OR = 1.55; 95% CI = 1.03 to 2.52; P = .04) were more likely to be overweight than the general population. No other age or diagnostic group had an increased risk of overweight. CONCLUSIONS: The prevalence of overweight was not increased in this cohort compared with the general population. However, almost 1/3 of these patients are overweight, necessitating a clinical and research focus on preventing and combating overweight in childhood cancer survivors.