Neonatology Staffing Practices- An In-Depth Exploration of Leaders' Perspectives.

OBJECTIVE: To describe neonatology leaders' perspectives on ideal staffing practices, including clinical work, non-clinical roles, shift characteristics, and flexibility. Although the current state of neonatology staffing issues is reported in the literature, a description of ideal, recommended staffing practices is lacking. STUDY DESIGN: We performed a qualitative study, using purposive sampling to interview 26 neonatology leaders. Semi-structured interviews included open-ended questions on ideal staffing practices in four categories: clinical and non-clinical aspects of work, shift characteristics, and flexibility in the work environment. We conducted a directed content qualitative analysis of interview transcripts. RESULTS: Leaders described their perspectives of ideal staffing practices. All clinical hours should count towards total clinical time and clinical full-time Equivalent (cFTE), and many non-clinical efforts should be compensated with time or money. Most stated varying workloads reflective of team structures and patient factors should be considered. Maximum in-house shift length should be <24 hours and weekend assignments should be equitable, irrespective of career track. Most endorsed flexibility at the individual physician level with a clear plan for covering variable staffing acute and chronic needs. CONCLUSIONS: Neonatology leaders recognize current staffing challenges and the need to evolve towards more ideal staffing practices. However, competing interests and complexities drive maintenance of the status quo and make change difficult for healthcare organizations and academic departments. Future work needs to create and measure optimal, standardized, and transparent staffing practices with appropriate adjustments for clinical, administrative, teaching, and scholarly obligations.

Medicaid and newborn care: challenges and opportunities.

Since its creation in 1965, Medicaid has operated as a federal-state partnership that provides a robust set of medical benefits to low-income families, including pregnant people and infants. In many ways, Medicaid has met its initial promise. However, medical benefits, provider payments, and key administrative procedures regarding eligibility, enrollment, and access to care vary substantially among state Medicaid programs. These variations have created profound inequities across states in the care of parents and children, particularly during pregnancy and in the postpartum and neonatal periods. Here we review select aspects of the Medicaid program pertinent to newborns and infants that contribute to eligibility and enrollment gaps, variations in benefits coverage and payment rates, and racial disparities in both access to healthcare and infant health outcomes. We outline a number of structural reforms of the Medicaid program that can improve newborn and infant access to care and outcomes and redress existing inequities.

Academic neonatologist-a species at the brink of extinction?

Neonatology is a field that is currently facing many challenges. These challenges include outdated work models in clinical environments with increasing acuity and patient workloads, physician burnout exacerbated by gender inequity and the recent COVID-19 pandemic, and inappropriate metrics to measure clinical productivity. Academic neonatologists have additional missions that include research, teaching, and scholarly productivity in the setting of an increasing clinical workload and reduced time and support for teaching and research. Within the university-based practice setting, reimbursement, and salary structure result in relatively low compensation for neonatologist clinical productivity and time. These challenges threaten the sustainability of academic neonatology as a field. Working towards potential solutions such as creation of sustainable, transparent work models, and aligned funds flow within university-based settings is imperative.

US state policies for Medicaid coverage of donor human milk.

Donor human milk is recommended by the American Academy of Pediatrics for high-risk infants when mother's own milk is absent or insufficient in quantity. Several factors may contribute to the inequitable use of or access to donor human milk, including a limited knowledge of its effects, cost, reimbursement, and regulatory barriers. The American Academy of Pediatrics and the United States Surgeon General have called for investigating barriers that prevent use of donor human milk for high-risk infants and for changes to public policy known to improve availability and affordability. We review the current legislative, regulatory, and economic landscape surrounding donor human milk use in the United States, as well as suggest state- and federal-level solutions to increase access to donor human milk.

Case of an unreported genetic variant of salt losing 3-ß-hydroxysteroid dehydrogenase deficiency.

Salt losing 3-ß-hydroxysteroid dehydrogenase deficiency (HSD3B2) is a rare form of congenital adrenal hyperplasia, seen in <0.5% of cases. We present a 7-year-old male diagnosed with HSD3B2 deficiency, not identified by state newborn screen, due to a novel variant identified in the HSD3B2 gene (c.694C > G; p.His232Asp). This patient was referred to pediatric endocrinology and pediatric biochemical genetics following a fourth hospitalization for emesis and electrolyte derangements including hyponatremia, hyperkalemia, ketoacidosis and hypoglycemia. Endocrinology evaluation yielded elevated 17-hydroxyprogesterone (17-OHP), 17-hydroxypregnenolone (17-OHPreg), dehydroepiandrosterone and adrenocorticotropic hormone (ACTH). ACTH stimulation test indicated flat response. Sequencing of the HSD3B2 revealed a pathogenic variant inherited in trans with the novel c.694C > G (p.His232Asp) variant. The patient was started on daily glucocorticoid and mineralocorticoid replacement and has since had no further adrenal crises.

Angiomatoid Fibrous Histiocytoma With Paraneoplastic Platelet Storage Pool Deficiency.

Angiomatoid fibrous histiocytoma is a rare soft tissue tumor usually discovered in young individuals. This tumor is often mistaken for a hematoma and typically misdiagnosed. It is commonly found in the extremities and may be associated with a site of recent or previous trauma. Characteristic histology includes nodules of histiocytoid spindle cells with pseudoangiomatoid spaces, fibrous pseudocapsules, and lymphoid cuffing. We describe the case of an 8-year-old girl who presented after incision and drainage of a superficial thigh lesion and experienced subsequent chronic bleeding of her wound. Her initial presentation was concerning for an underlying bleeding disorder, and laboratory analysis uncovered a paraneoplastic platelet function disorder that resolved with therapy of the primary tumor.

Type 1 Diabetes Mellitus: Pediatric Team-Based Learning Module.

INTRODUCTION: Type 1 diabetes mellitus (T1DM) is an autoimmune disease that impacts roughly 200,000 youths in the United States. Many patients have limited access to specialist care. Therefore, general pediatricians are expected to be skilled in the management of diabetes. Recent studies suggest that an educational gap exists for general practitioners regarding diabetes care. Team-based learning (TBL), an active, learner-centered method of teaching, has been shown to be an effective tool in adult learning and teaching. Here, we outline a TBL activity focused on the education of pediatric residents in the comprehensive management of T1DM. METHODS: Learners prepare in advance by reading through a review article on T1DM. They are formed into groups and work through the readiness assurance process first, followed by application exercises. The application exercises focus on choosing and applying an insulin regimen to a patient with a new diagnosis of T1DM, including modification of this regimen based on blood sugar trends, management of diabetes ketoacidosis, and recognition and management of hypoglycemia. RESULTS: Learners showed improvement in their readiness assurance testing, from 81.4% individually to 91% as a group. Eighty percent of learners agreed or strongly agreed this was an effective method for improving diabetes skills and knowledge, and the learning process engaged them. DISCUSSION: TBL may be a valuable educational strategy to enhance knowledge of T1DM care for general pediatricians. Future studies focusing on longitudinal educational outcomes would be beneficial.

Aligning Practice to Policies: Changing the Culture to Recognize and Reward Teaching at Research Universities.

Recent calls for improvement in undergraduate education within STEM (science, technology, engineering, and mathematics) disciplines are hampered by the methods used to evaluate teaching effectiveness. Faculty members at research universities are commonly assessed and promoted mainly on the basis of research success. To improve the quality of undergraduate teaching across all disciplines, not only STEM fields, requires creating an environment wherein continuous improvement of teaching is valued, assessed, and rewarded at various stages of a faculty member's career. This requires consistent application of policies that reflect well-established best practices for evaluating teaching at the department, college, and university levels. Evidence shows most teaching evaluation practices do not reflect stated policies, even when the policies specifically espouse teaching as a value. Thus, alignment of practice to policy is a major barrier to establishing a culture in which teaching is valued. Situated in the context of current national efforts to improve undergraduate STEM education, including the Association of American Universities Undergraduate STEM Education Initiative, this essay discusses four guiding principles for aligning practice with stated priorities in formal policies: 1) enhancing the role of deans and chairs; 2) effectively using the hiring process; 3) improving communication; and 4) improving the understanding of teaching as a scholarly activity. In addition, three specific examples of efforts to improve the practice of evaluating teaching are presented as examples: 1) Three Bucket Model of merit review at the University of California, Irvine; (2) Evaluation of Teaching Rubric, University of Kansas; and (3) Teaching Quality Framework, University of Colorado, Boulder. These examples provide flexible criteria to holistically evaluate and improve the quality of teaching across the diverse institutions comprising modern higher education.