Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis.

OBJECTIVE: Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program. METHODS: This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses. RESULTS: Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents. CONCLUSIONS: There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment.

PURPOSE: To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment. METHOD: A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model. RESULTS: ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs. CONCLUSIONS: CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

A child with eosinophilia, Loeffler endocarditis, and acute lymphoblastic leukemia.

We present an 8-year-old male with Loeffler endocarditis and acute lymphoblastic leukemia with hypereosinophilia (ALL/Eo) who initially presented with a 3-month history of peripheral eosinophilia thought to be due to visceral larval migrans. Despite treatment for Toxocara, his leukocytosis persisted and he developed mitral valve insufficiency and congestive heart failure. Myocardial biopsy revealed fibrosis and thrombus formation indicative of Loeffler endocarditis, and a peripheral smear showed pre-B-cell acute lymphoid leukemia. This unique case highlights a rare, yet serious sequella of prolonged eosinophilia.