"To Call or Not to Call" Communication Preferences Among Pediatric Hospital Medicine Team Leaders.

OBJECTIVES: Pediatric Hospital Medicine fellowship programs need to abide by Accreditation Council for Graduate Medical Education requirements regarding communication and supervision. Effective communication is critical for safe patient care, yet no prior research has explored optimal communication practices between residents, fellows, and attending hospitalists. Our objective is to explore communication preferences among pediatric senior residents (SRs), Pediatric Hospital Medicine fellows, and hospitalists on an inpatient team during clinical decision-making. METHODS: We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys adapted from prior research, 1 for each population: 200 hospitalists, 20 fellows, and 380 SRs. The instruments included questions about communication preferences between the SR, fellow, and hospitalist during clinical scenarios. We calculated univariate descriptive statistics and examined paired differences in percent agreement using χ2 tests, accounting for clustering by institution. RESULTS: Response rates were: 53% hospitalists; 100% fellows; 39% SRs. Communication preferences varied based on role, scenario, and time of day. For most situations, hospitalists preferred more communication with the fellow overnight and when a patient or family is upset than expressed by fellows (P < .01). Hospitalists also desired more communication between the SR and fellow for an upset patient or family than SRs (P < .01), but all respondents agreed the SR should call the fellow for adverse events. More fellows and hospitalists felt that the SR should contact the fellow before placing a consult compared with SRs (95%, 86% vs 64%). CONCLUSIONS: Hospitalists, fellows, and SRs may have differing preferences regarding communication, impacting supervision, autonomy, and patient safety. Training programs should consider such perspectives when creating expectations and communication guidelines.

Feasibility and Acceptability of Virtual Rounds on an Academic Inpatient Pediatric Unit.

OBJECTIVES: Virtual rounds enable remote participation in bedside clinical encounters. Their effects on education remain poorly characterized and limited by lack of foundational evidence establishing that this approach is welcomed among learners and educators. We assessed technical feasibility and acceptability of incorporating video conferencing into daily work rounds of pediatric residents and attending physicians. METHODS: We conducted a cross-sectional survey-based study of attending observers and pediatric residents participating in rounds both at the bedside and via video teleconferencing from September to December 2020. Participant experiences were assessed and summarized using parametric Likert-type questions regarding technical issues, efficiency, educational experience, and engagement. Associations between technical aspects and individual perceptions of virtual rounds and self-reported engagement were also measured. RESULTS: Of 75 encounters, 29% experienced technical issues, 45% of which were attributable to a low-quality tablet stand. Negative impacts of virtual rounding on efficiency were reported in 6% of responses. Virtual participants were engaged (70%) and reported educational value for 65% of encounters. Comfort with virtually asking questions (odds ratio 3.3; 95% confidence interval 2.0-5.7) and performing clinical tasks for other patients (odds ratio 0.42; 95% confidence interval 0.2-0.9) were associated with engagement (P <.05). CONCLUSIONS: Virtual participation in rounds was technically feasible and maintained educational value and engagement for residents in the majority of encounters, without sacrificing efficiency. Even as restrictions from the coronavirus disease 2019 pandemic are lifted, this rounding model has many important applications, including increasing educational opportunities for remote learners and making multidisciplinary rounds more accessible.

Defining Supervision Preferences and Roles Within a New Subspecialty: Pediatric Hospital Medicine.

OBJECTIVE: To describe supervision preferences among pediatric hospitalists, Pediatric Hospital Medicine (PHM) fellows, and senior residents (SRs), and to better define the ideal role of a PHM fellow. METHODS: We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys, one for each population (hospitalists, fellows, SRs). We calculated univariate descriptive and bivariate statistics for categorical variables using Chi-square tests with the Rao-Scott correction to account for clustering by institution. RESULTS: Survey respondents included 106 of 200 hospitalists (53%), all 20 fellows (100%), and 149 of 380 SRs (39%). Most hospitalists and all fellows preferred the supervising hospitalist to have 3+ years of experience or be fellowship-trained. Nearly all fellows preferred the attending round in-person providing progressive independence; while hospitalists and SRs desired greater attending presence on rounds. Hospitalists and fellows wanted more frequent communication when the attending does not round with the team, and more hospitalists desired at least 2 points of contact regardless of attending presence on rounds. Fifty-five percent of SRs reported experiencing much less/less autonomy when on with a fellow than when supervised by a hospitalist only. Regarding the fellow's role, most participants agreed SRs should lead rounds and contact the fellow first with questions. The majority agreed teaching should be a shared responsibility but lacked consensus about how to provide feedback. CONCLUSIONS: Study results reveal preferences about supervising fellows in this new subspecialty. Hospitalists, fellows, and SRs may have differing opinions regarding workflow, communication, and teaching, impacting team leadership and autonomy.

Yes, we CAM: Increasing physician communication about complementary and alternative medicine through electronic medical record prompts in a pediatric hospital.

BACKGROUND AND PURPOSE: Over half of patients utilize complementary and alternative medicine (CAM), yet fewer than 10 % of physicians inquire about use. This prospective cohort study sought to increase patient-provider communication about CAM through electronic medical record (EMR) prompts and education, as well as study concordance rates of physician and nursing CAM-related documentation. MATERIALS AND METHODS: Recordings in history and physical (H&P) documents authored by first-year pediatric residents were used as a proxy for communication. Rates of documentation were assessed at baseline, after the introduction of an EMR prompt, and after an educational intervention. Nursing documentation was compared with resident documents to assess rates of concordance regarding CAM-related documentation. RESULTS: Baseline CAM-related documentation rate was 24 % and increased to 50 % after introducing an EMR CAM prompt (p < 0.001). No significant change occurred after education: 38 % had CAM-related documentation (p = 0.09). Physician and nursing documentation concordance rates were 58 % at baseline, 48 % after introduction of prompts, and 35 % after introducing education. CONCLUSION: Visual cues alone may be effective in increasing patient-provider communication about CAM, though low concordance between physician and nursing documentation may suggest variability in how CAM is defined and inquired about.

The Pediatric Hospital Medicine Core Competencies: 2020 Revision.

BACKGROUND: The Pediatric Hospital Medicine (PHM) Core Competencies define the expertise required of practitioners and provide a framework for educational activities. Since initial publication in 2010, the scope of practice for pediatric hospitalists has evolved in clinical, research, administrative, and educational arenas. OBJECTIVE: To describe the methodology utilized in the revision of The PHM Core Competencies to ensure a product reflective of current roles and expectations for pediatric hospitalists across all training pathways and practice settings. METHODS: The Society of Hospital Medicine (SHM) Pediatrics Special Interest Group supported the initiation of the revision. A diverse group of editors and authors was engaged from among members of SHM, the American Academy of Pediatrics and the Academic Pediatrics Association. Editorial roles were expanded to represent all practice settings. More than 80 individuals contributed, representing both university and community sites, and all US geographic regions. Editors conducted a two-part needs assessment; a survey related to content was distributed to the PHM community and content from recent conferences and PHM related publications was reviewed. The final compendium consists of 4 sections and 66 chapters, including 12 new chapters and 36 chapters with substantial changes. Individual chapters and the entire compendium underwent rigorous internal and external review. CONCLUSION: The PHM Core Competencies: 2020 Revision reflects the work of a broad spectrum of PHM practitioners responding to the practice and educational changes in PHM over the past decade. The compendium can inform education, training, and career development for pediatric hospitalists practicing now and in coming years.

How Do Pediatric Hospital Medicine Fellowships Prepare Graduates as Educators? A Survey of Program Directors and Graduates in the United States.

Pediatric hospital medicine (PHM) is the newest recognized subspecialty in pediatrics within the United States. While fellowships in PHM have been available for several years, completion of a 2-year fellowship has become a requirement for subspecialty certification. Pediatric hospitalists provide substantial teaching to trainees, and therefore, PHM fellowships must include dedicated training around teaching and medical education. The purpose of this study was to determine how current PHM fellowships prepare graduates for their roles as medical educators. Two surveys were developed from the published PHM core competencies and Entrustable Professional Activities for pediatric subspecialties. One survey was disseminated to all active PHM program directors and the second was disseminated to all PHM fellowship graduates who completed training between 2012 and 2016. Items included those related to program structure and training/assessment in medical education. A total of 21 program directors (response rate = 58%) and 46 fellowship graduates (response rate = 46%) participated in the survey. All graduates (100%) reported teaching learners in their current setting. Many (67%) fellowship programs offered formal training in medical education, and this is greater than the 50% that was previously described. Direct observation (71%) was the most common method of assessment. Most graduates reported their fellowship provided optimal training in feedback and teaching during family centered rounds but suboptimal training in other skills such as curriculum development. The results of this study highlight areas for improvement in fellowship curriculum and assessment to better prepare fellows for their roles as educators.

Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty.

OBJECTIVE: To identify factors that influence faculty to promote or reduce the expression of autonomy for pediatric hospital medicine (PHM) fellows and describe behaviors faculty employ to support fellow autonomy in the clinical setting. METHODS: This was a multicenter, qualitative study using semistructured interviews with core faculty in PHM fellowships. Data were transcribed verbatim and analyzed using a phenomenological approach. Each transcript was coded independently by 2 trained reviewers who then met to reconcile differences. Codes were identified using an iterative approach and organized into themes. Investigators engaged in peer debriefing during data collection, and member checking confirmed the results. RESULTS: Interviews were conducted December 2016 to January 2017 with 20 faculty from 5 PHM fellowships. Most participants were female (12, 60%) and assistant (13, 65%) or associate (6, 30%) professors. Data analysis yielded 6 themes. Themes reflect the importance of faculty experience, style, and approach to balancing patient care with education in the provision of autonomy for PHM fellows. Faculty appreciation for the role of autonomy in medical education, investment in their roles as educators, and investment in PHM fellowship training are also influential factors. Finally, fellow clinical, educational, leadership, and communication skills influence the provision of autonomy. Faculty employ various levels of supervision, scaffolding techniques, and direct observation with feedback to support fellow autonomy. Professional development was considered essential for developing these skills. CONCLUSIONS: We identified 6 themes related to faculty provision of autonomy to PHM fellows, as well as strategies employed by faculty to support fellow autonomy.

Current Practices and Perspectives on Peer Observation and Feedback: A National Survey.

OBJECTIVE: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF. METHODS: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States. RESULTS: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%). CONCLUSIONS: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs.

Current Perspectives on Transport Medicine in Pediatric Hospital Medicine Fellowships.

Transport medicine (TM) is a Pediatric Hospital Medicine (PHM) Core Competency and part of the proposed PHM fellowship curricular framework. No published TM curricula are available. This cross-sectional study was designed to determine attitudes toward TM training among PHM fellowship stakeholders and conduct a TM curriculum needs assessment. Unique, web-based, anonymous surveys for PHM fellows, graduates, and program directors (PDs) were administered, with response rates of 57%, 37%, and 44%, respectively. Fellows' interest in completing a TM rotation is greater than their perceived interest by PDs (P = .06). Graduates who completed a TM rotation were more likely to recommend a TM rotation than those who did not (P = .001). Perceived barriers included lack of a formal TM curriculum and time constraints. Stabilizing patients and triage of referrals were deemed important learning objectives, and active learning strategies were prioritized. Curriculum design should focus on topics specific to the transport process and environment.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships.

Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field's evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.

Current Roles and Perceived Needs of Pediatric Hospital Medicine Fellowship Graduates.

OBJECTIVES: Pediatric hospitalists report the need for additional training in clinical and nonclinical domains. Pediatric hospital medicine (PHM) fellowships seek to provide this training and produce leaders in the field. Our objective is to describe current roles and perceived training needs of PHM fellowship graduates. METHODS: In 2014, all PHM fellowship graduates were asked to complete a Web-based survey. Survey questions addressed demographics, past training, current roles, and training needs in clinical care, research, education, and administration. Associations between fellowship experiences and outcomes were examined. RESULTS: Fifty-one of 61 eligible individuals completed the survey. Average duration as a pediatric hospitalist was 5 years. Ninety percent completed pediatric categorical residency, whereas 10% completed an Internal Medicine-Pediatrics Residency. Most respondents completed a 1- (38%) or 2-year (46%) fellowship program. Ninety-six percent of respondents currently work in academic environments. The perceived need for additional clinical training was low, except procedures (44%). Nearly all teach medical students and pediatric residents, reporting adequate training in variety of teaching strategies. The majority of respondents conduct research, most commonly quality improvement (QI; 67%) and education (52%). Two-thirds are first authors on at least 1 peer-reviewed article. Research training needs include QI methodology (44%), biostatistics (43%), and obtaining funding (54%). A considerable number of respondents have academic leadership positions. CONCLUSIONS: PHM fellowship graduates are academic hospitalists with diverse responsibilities. Despite a short average career span, many have achieved leadership roles and been academically productive. Future curriculum development should focus on procedures, QI, and research training.

The current state of pediatric hospital medicine fellowships: A survey of program directors.

BACKGROUND: Pediatric hospital medicine (PHM) fellowship programs have grown rapidly over the last 20 years and have varied in duration and content. In an effort to standardize training in the absence of a single accrediting body, PHM fellowship directors now meet annually to discuss strategies for standardizing and enhancing training. OBJECTIVES: To explore similarities and differences in curricular structure among PHM fellowship programs in an effort to inform future curriculum standardization efforts. METHODS: An electronic survey was distributed by e-mail to all PHM fellowship directors in April 2014. The survey consisted of 30 multiple-choice and short-answer questions focused on various curricular aspects of training developed by the authors. RESULTS: Twenty-seven of 31 fellowship programs (87%) responded to the survey. Duration of most programs was 2 years (63%), with 6, 1-year programs (22%) and 4 (15%) 3-year programs making up the remainder. The average amount of clinical time among programs was 50% (range approximately 20%-65%). In addition to general inpatient pediatric service time, most programs require other clinical rotations. The majority of programs allow fellows to bill independently for their services. Most programs offer certificate courses, courses for credit or noncredit courses, with 11 programs offering masters' degrees. Twenty-one (81%) programs provide a scholarship oversight committee for their fellows. Current fellows' primary areas of research are varied. CONCLUSION: Though variability exists regarding program length, clinical composition, and nonclinical offerings, several common themes emerged that may help inform the development of a standard curriculum for use across all programs. This information provides a useful starting point if pediatric hospital medicine obtains formal subspecialty status. Journal of Hospital Medicine 2016;11:324-328. © 2016 Society of Hospital Medicine.

Pediatric hospitalists in medical education: current roles and future directions.

As the field of pediatric hospital medicine has evolved, pediatric hospitalists have become increasingly involved in medical student and resident education--providing direct education during clinical rotations, developing novel curricula to meet the demands of the new educational environment, occupying leadership roles in medical education, and more. The literature suggests that hospitalists possess the essential skills for teaching effectively, yet most hospitalists feel that additional training beyond residency is necessary to refine their knowledge and skills in education and in other essential domains. Several pediatric hospital medicine fellowships and continuing medical education activities have been developed in the last decade to meet this growing need. The recent publication of the Pediatric Hospital Medicine Core Competencies will help define the roles and expectations of practicing pediatric hospitalists, and will serve as a framework for future curriculum development in both graduate and continuing medical education.

Pediatric hospital medicine core competencies: development and methodology.

BACKGROUND: Pediatric hospital medicine is the most rapidly growing site-based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed. METHODS: In 2005, SHM's Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM. RESULTS: The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalist's responsibility to advance systems of care. CONCLUSION: These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices.

Is tolerance induction the answer to adolescent non-adherence?

By definition, tolerance will eliminate the problem of adolescent medication non-adherence. Although adolescents' propensity toward non-adherence makes them at first glance to be particularly attractive candidates for tolerance trials, there are also immunologic, psychosocial and ethical barriers that temper enthusiasm for their inclusion at present. Limits in emotional and cognitive maturity are combined during the teenage years with adult-like immunologic maturity to lessen the potential for successful implementation of tolerance and near tolerance strategies. Alternatively, an interval step to tolerance in adolescents is to eliminate the medications most likely contributing to non-adherence through harsh side effects such as steroids and calcineurin inhibitors. This manuscript will review the general topic of transplantation tolerance with specific attention given to the application of pro-tolerant therapies in adolescent recipients.