Terminal anorexia nervosa: three cases and proposed clinical characteristics.

BACKGROUND: Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful. No level of harm reduction proves achievable or adequately ameliorates their suffering. In this subgroup, many of those with anorexia nervosa will experience the medical consequences of malnutrition as their future cause of death. Whereas anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so, some patients simply cannot continue to fight. They recognize that death from anorexia nervosa, while perhaps not welcome, will be inevitable. Unfortunately, these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa. CASE PRESENTATION: Three case studies elucidate this condition. One patient was so passionate about this topic that she asked to be a posthumous co-author of this paper. CONCLUSIONS: Consistent with literature on managing terminal illness, this article proposes clinical characteristics of patients who may be considered to have a terminal eating disorder: diagnosis of anorexia nervosa, older age (e.g. age over 30), previous participation in high quality care, and clear and consistent determination by a patient who possesses decision-making capacity that additional treatment would be futile, knowing their actions will result in death. By proposing the clinical characteristics of terminal anorexia nervosa, we hope to educate, inspire compassion, and help providers properly assess these patients and provide appropriate care. We hope that this proposal stimulates further expert consensus definitions and clinical guidelines for management of this population. In our view, these patients deserve the same attendant care and rights as all other patients with terminal illness, up to and including medical aid in dying in jurisdictions where such care is legal.

Medical student perspectives on conducting patient experience debrief interviews with hospitalized children and their families.

PURPOSE: To explore how medical students completing a pediatric clerkship viewed the benefits and barriers of debrief interviews with hospitalized patients and families. METHODS: In this study, focus groups were conducted with pediatric clerkship students after completion of a debrief interview. The constant comparative method was used with Mezirow's transformative learning theory as a lens to explore perceptions of the benefits and challenges of performing the interview. RESULTS: Focus groups revealed five benefits and two challenges. The benefits were that the debrief interviews helped students (1) humanize patients and appreciate social and environmental influences on patient health, (2) assess caregiver/patient understanding about care to correct misunderstandings, (3) actively involve caregivers/patients in treatment plan development, (4) engage patients in active expression of questions/concerns, and (5) recognize the value of their own role on the healthcare team. The challenges were that students felt (1) a lack of knowledge to answer caregivers'/patients' questions about diagnoses and (2) discomfort responding to caregiver/patient frustration, anxiety, or sadness. Student feedback on feasibility and implementation led to guidelines for selecting patients and conducting small group discussions after the debrief interviews. CONCLUSIONS: Debrief interviews offer a unique approach for learners to explore patient perspectives during hospitalization through direct patient engagement and dialogue, contributing to professional development, empathy, and potentially more positive patient care experiences.

What Makes the "Perfect" Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives.

PURPOSE: To characterize the methods of inpatient consult communication, given new communication modalities; to explore residents' and fellows' perspectives on the ideal consult and how this consult could affect their teaching, learning, and patient safety; and to identify barriers to and strategies for optimizing consultations. METHOD: Using qualitative grounded theory, the authors conducted semistructured focus groups with pediatric residents and fellows at Lucile Packard Children's Hospital at Stanford University from October 2016 to September 2017, using questions developed by expert consensus to address study objectives. Sessions were audiorecorded and transcribed verbatim. Two authors independently coded the transcripts and reconciled codes to develop categories and themes using constant comparison. The third author validated the codes, categories, and themes. To ensure trustworthiness, participants edited the themes for accuracy. RESULTS: Twenty-seven residents and 16 fellows participated in 7 focus groups (3 with residents, 4 with fellows). Four themes emerged: (1) Many forms of communication are successfully used for initial inpatient consult recommendations (in person, phone, text messages, notes in electronic medical records); (2) residents and fellows prefer in-person communication for consults, believing it leads to improved teaching, learning, and patient safety; (3) multiple strategies can optimize consults regardless of communication modality; and (4) how residents frame the initial consult affects the interaction and can increase fellow engagement, which leads to more fellow teaching, residents' improved understanding, and better patient care. CONCLUSIONS: Residents and fellows believe that structured initial consults conducted in person improve teaching, learning, and patient care. Several strategies exist to optimize this process.

The Patient Experience Debrief Interview: How Conversations With Hospitalized Families Influence Medical Student Learning and Reflection.

PURPOSE: To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning. METHOD: The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from May 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Interrater reliability was examined using kappa. REFLECT scores were analyzed using a chi-square test; essays were analyzed using content analysis. RESULTS: Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the 2 highest levels of reflection, compared with 71% of the intervention group; 2% of the control group attained critical reflection, the highest level, compared with 31% of the intervention group (χ(3, N = 189) = 33.9, P < .001). Seven themes were seen across both groups, 3 focused on physician practice and 4 focused on patients. Patient-centered themes were more common in the intervention group, whereas physician-focused themes were more common in the control group. CONCLUSIONS: Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.

Suicide Risk Assessment and Management Training Practices in Pediatric Residency Programs: A Nationwide Needs Assessment Survey.

PURPOSE: Youth suicide is a public health emergency, and its prevention is a national imperative. Pediatric providers are critical to risk assessment, triage, and intervention, yet little is known about the content, quality, and perceived adequacy of suicide prevention pediatric residency training. We thus sought to (1) characterize suicide risk assessment and management training practices in pediatric residency programs nationwide and (2) assess areas of training need to guide curricular development. METHODS: An online nationwide needs assessment was distributed to all 204 pediatric residency program directors (PDs) and 494 pediatric chief residents (CRs) through the Association of Pediatric Program Directors listservs (May to June 2017). Descriptive statistics and comparisons between PDs and CRs are reported. RESULTS: Ninety-five PDs and 210 CRs (47% and 43% response rate, respectively) completed the survey. Although 82% of respondents rated suicide prevention training in residency as "very" or "extremely" important, a minority (18% PDs and 10% CRs) reported adequate preparation relative to need. Formal training was not universal (66% PDs and 45% CRs) and practices varied across programs (PD median = 3 hours [interquartile range: 1-4.5 hours], CR median = 1.5 hours [interquartile range: 0-3 hours]). Top-ranked educational priorities included interviewing adolescents about risk, risk factor identification, and locating community resources. Training barriers included limited time, lack of training resources, and need for additional expert faculty to guide training. CONCLUSIONS: PDs and CRs reported constraints to suicide prevention training for pediatric residents despite high perceived importance and need. Programs may benefit from explicit guidelines and standardized curricula that emphasize educational priorities, building on these findings.

Illuminating exemplary professionalism using appreciative inquiry dialogues between students and mentors.

PURPOSE: To explore the types of exemplary professional behaviors and the facilitators and barriers to professional behavior discussed by student-mentor dyads during appreciative inquiry (AI) dialogs. MATERIALS AND METHODS: We conducted a qualitative analysis of AI narratives discussing exemplary professional practice written by third-year medical students following a dialog with mentors. Narratives were thematically analyzed using directed content analysis to explore the types of exemplary professional behaviors discussed and the facilitators and barriers to professional practice. Narratives were coded independently by two investigators; codes were finalized, themes were derived, and a model on how exemplary professional behaviors are nurtured and reinforced was developed. RESULTS: Themes addressed humanism toward others and excellence, with altruism being an underlying implicit guiding principle behind professional behavior. Humanism toward self was infrequently discussed as an aspect of professionalism, but when discussed, was perceived to foster resilience. Principle-based attitudes and emotional intelligence facilitated professional behaviors. Programmatic scaffolds facilitated professional behavior and included curricula on reflective practice, mentorship, promoting learner autonomy and connectedness, and a safe environment. CONCLUSIONS: AI is an effective strategy that can be used to stimulate learner reflection on professionalism, humanism, and wellness and promote learner acknowledgement of positive aspects of the learning environment.

The Golden Ticket Project for peer recognition.

BACKGROUND: A supportive working environment can be protective against burnout in residency training. To help foster a positive culture, we developed the 'Golden Ticket Project' (GTP) and evaluated it as a tool for peer appreciation. METHODS: In October 2013-July 2014, all paediatric residents (n = 83) at a paediatric residency programme were invited to participate in the GTP. Through an electronic form, residents could award a co-resident with a 'Golden Ticket' for any behaviour that they were grateful for. Two authors manually coded and analysed the tickets using content analysis to identify recurring themes. We also distributed an anonymous survey to all residents to assess their attitudes toward the GTP. RESULTS: The majority (61%) of residents either gave or received 'Golden Tickets' (51/83). Reasons for receiving tickets fell into five categories: (i) teamwork; (ii) positive attitude; (iii) patient care; (iv) resident-resident support; and (v) supervisory skills. Across all three classes, teamwork was recognised most frequently, noted in 43% of all tickets. The recognition of other behaviours varied by class. Fifty-five percent (46/83) of residents completed the programme evaluation survey. Seventy-six percent (35/46) of respondents wanted the programme to continue; of those, 49% (17/35) 'agreed' or 'strongly agreed' that they were 'more aware of acts of kindness in the residency program because of the GTP'. A supportive working environment can be protective against burnout in residency training DISCUSSION: The GTP is a feasible and valued peer-support initiative for residents. The GTP characterised behaviours and attitudes that residents were grateful for in their peers. These behaviours could inform the development of wellness interventions for residents that focus on building supportive working environments.

The Effect of Faculty Coaching on Resident Attitudes, Confidence, and Patient-Rated Communication: A Multi-Institutional Randomized Controlled Trial.

OBJECTIVE: Despite a national focus on physician-patient communication, there is a paucity of literature on how patient and family feedback (PFF) can be used as a tool to help residents learn communication skills. The purpose of this study was to assess the effect of coaching on residents' attitudes towards PFF, self-confidence in communication, and patient-rated communication skills. METHODS: This was an institutional review board-approved, randomized-controlled trial with pediatric residents at 3 institutions from 2015 to 2016. Pre- and postintervention, residents completed a self-assessment of their attitudes and self-confidence in communication. PFF was collected for each resident using the Communication Assessment Tool, which has been validated in other medical disciplines. Intervention group residents reviewed their baseline PFF with a faculty coach; control group residents reviewed their PFF independently. RESULTS: In total, 114 residents completed the study, 57 in each arm. Intervention group residents were significantly more likely to ask for PFF compared with control group residents (mean change 0.36 vs -0.11, P = .01). There were no other significant differences in resident attitudes, confidence, or patient-rated communication between groups. Both groups had increased self-confidence over time and with increasing postgraduate year level. Patient ratings of resident communication did not differ over time or between groups. CONCLUSIONS: Residents who reviewed PFF with a faculty coach were significantly more likely to report they would ask patients for feedback than residents who reviewed PFF independently, suggesting review of feedback with a coach may enhance appreciation of patient feedback. Although self-confidence improved over time in both groups, patient ratings of resident communication skills were not significantly different over time or between groups.

De-escalating Angry Caregivers: A Randomized Controlled Trial of a Novel Communication Curriculum for Pediatric Residents.

OBJECTIVE: Medical providers struggle when communicating with angry patients and their caregivers. Pediatric residents perceive communication competencies as an important priority for learning, yet they lack confidence and desire more training in communicating with angry families. Few curricula exist to support trainees with de-escalation skill development. We developed, implemented, and evaluated the impact of a novel de-escalation curriculum on pediatric resident communication skills. METHODS: We conducted a randomized controlled trial of a 90-minute de-escalation curriculum for pediatric residents from August to September 2016. Trained standardized patient (SP) actors rated residents' communication skills following 2 unique encounters before and after the intervention or control sessions. Residents completed a retrospective pre/post communication skills self-assessment and curriculum evaluation. We used independent and paired t-tests to assess for communication improvements. RESULTS: Eighty-four of 88 (95%) eligible residents participated (43 intervention, 41 control). Residents reported frequent encounters with angry caregivers. At baseline, interns had significantly lower mean SP-rated de-escalation skills than other residents (P = .03). Intervention residents did not improve significantly more than controls on their pre/post change in mean SP-rated de-escalation skills; however, intervention residents improved significantly on their pre/post mean self-assessed de-escalation skills (P ≤ .03). CONCLUSIONS: Despite significant self-assessed improvements, residents' SP-rated de-escalation skills did not improve following a skills-based intervention. Nevertheless, our study illustrates the need for de-escalation curricula focused on strategies and peer discussion, suggests optimal timing of delivery during fall of intern year, and offers an assessment tool for exploration in future studies.

The Challenges of Multisource Feedback: Feasibility and Acceptability of Gathering Patient Feedback for Pediatric Residents.

OBJECTIVE: The Accreditation Council for Graduate Medical Education calls for residency programs to incorporate multisource feedback, which may include patient feedback, into resident competency assessments. Program directors face numerous challenges in gathering this feedback. This study assesses the feasibility and acceptability of patient feedback collection in the inpatient and outpatient setting at 3 institutions. METHODS: Patient feedback was collected using a modified version of the Communication Assessment Tool (CAT). Trained research assistants administered the CAT to eligible patients and families in pediatric ward, intensive care, and outpatient settings from July to October 2015. Completion rates and reasons for non-completion were recorded. Patient satisfaction with the CAT was assessed on a 5-point Likert scale. RESULTS: The CAT was completed by 860/1413 (61%) patients. Completion rates in the pediatric ward and intensive care settings were 45% and 38%, respectively, compared to 91% in the outpatient setting. In inpatient settings, survey non-completion was typically due to participant unavailability; this was rarely a reason in the outpatient setting. A total of 93.4% of patients were satisfied or very satisfied with using the CAT. It was found that 6.36 hours of research assistant time would be required to gather a valid quantity of patient feedback for a single resident in the outpatient setting, compared to 10.14 hours in the inpatient setting. CONCLUSIONS: Although collecting feedback using our standardized protocol is acceptable to patients, obtaining sufficient feedback requires overcoming several barriers and a sizable time commitment. Feedback collection in the outpatient setting may be higher yield than in the inpatient setting due to greater patient/family availability. Future work should focus on innovative methods to gather patient feedback in the inpatient setting to provide program directors with a holistic view of their residents' communication skills.

Yoga as adjunct therapy for adolescents with inflammatory bowel disease: A pilot clinical trial.

OBJECTIVES: To determine whether utilizing yoga as an adjunctive therapy to the medical standard of care for adolescents with inflammatory bowel disease (IBD) is: (1) feasible and acceptable, (2) effective in reducing disease severity, intestinal inflammation and improving wellness. DESIGN: Prospective, non-randomized, 8-week pilot study for adolescents with a diagnosis of IBD. Feasibility and acceptability of the intervention were assessed weekly and post-intervention via surveys and a focus group (week 8). Disease severity, intestinal inflammation, and wellness measures were assessed at baseline and post-intervention (week 8). INTERVENTION: Over the 8-week study period, patients were assigned three 60-minute, in-person yoga classes at weeks 1, 3 and 8, and three 30-minute, online yoga videos per week. MAIN OUTCOME MEASURES: Primary outcome measures were feasibility and acceptability. Secondary outcome measures assessed preliminary clinical efficacy by examining pre- and post-intervention change in disease severity (PUCAI), intestinal inflammation (fecal calprotectin), and six wellness measures (PROMIS-37). RESULTS: Nine adolescents with IBD participated. Eight participated in one or more yoga videos per week and all nine attended at least two in-person yoga classes. Focus group themes revealed that the intervention was well liked, with all participants reporting reduced stress, improved emotional self-awareness, and increased ability to identify and manage the physical symptoms of IBD. Participants had difficulty, however, completing the yoga videos due to time limitations and competing priorities. We lacked power to detect any statistically significant changes in PUCAI, calprotectin, or any of the six PROMIS-37 domains. CONCLUSIONS: A combination of in-person instructor led yoga with video-based yoga is a feasible and acceptable adjunct therapy for adolescents with IBD. Participants reported reduced stress and improved ability to identify and manage physical symptoms. A larger, randomized controlled trial is necessary to determine if the yoga protocol results in clinically and statistically significant improvements in inflammatory biomarkers and patient reported outcomes.

How Residents Learn From Patient Feedback: A Multi-Institutional Qualitative Study of Pediatrics Residents' Perspectives.

BACKGROUND: Residents may view feedback from patients and their families with greater skepticism than feedback from supervisors and peers. While discussing patient and family feedback with faculty may improve residents' acceptance of feedback and learning, specific strategies have not been identified. OBJECTIVE: We explored pediatrics residents' perspectives of patient feedback and identified strategies that promote residents' reflection on and learning from feedback. METHODS: In this multi-institutional, qualitative study conducted in June and July 2016, we conducted focus groups with a purposive sample of pediatrics residents after their participation in a randomized controlled trial in which they received written patient feedback and either discussed it with faculty or reviewed it independently. Focus group transcripts were audiorecorded, transcribed, and analyzed for themes using the constant comparative approach associated with grounded theory. RESULTS: Thirty-six of 92 (39%) residents participated in 7 focus groups. Four themes emerged: (1) residents valued patient feedback but felt it may lack the specificity they desire; (2) discussing feedback with a trusted faculty member was helpful for self-reflection; (3) residents identified 5 strategies faculty used to facilitate their openness to and acceptance of patient feedback (eg, help resident overcome emotional responses to feedback and situate feedback in the context of lifelong learning); and (4) residents' perceptions of feedback credibility improved when faculty observed patient encounters and solicited feedback on the resident's behalf prior to discussions. CONCLUSIONS: Discussing patient feedback with faculty provided important scaffolding to enhance residents' openness to and reflection on patient feedback.

Patient Feedback Requirements for Medical Students: Do Perceived Risks Outweigh the Benefits?

Patient feedback has increasingly become part of medical students' training and formative assessment. We conducted a qualitative study using focus groups to explore students' experiences soliciting patient feedback, including the benefits, challenges, and potential strategies to obtain it. Fifteen medical students participated. Thematic analysis revealed students' (1) discomfort soliciting feedback and concern of being viewed as self-serving; (2) concerns about eroding patient trust; (3) indifference to nonspecific, positive feedback; and (4) belief that informally solicited feedback is most helpful for their learning. Strategies for soliciting more useful patient feedback included (1) team-based solicitation, (2) empowering patients as teachers, and (3) development of feedback instruments that allow patients to comment on specific student-identified learning goals. Solicitation of patient feedback is challenging for medical students and provokes discomfort. Strategies to integrate patient feedback into medical student training and assessment must attend to students' needs so the value of patient feedback can be realized.

Reflective Practice in the Clinical Setting: A Multi-Institutional Qualitative Study of Pediatric Faculty and Residents.

PURPOSE: To explore when and in what form pediatric faculty and residents practice reflection. METHOD: From February to June 2015, the authors conducted focus groups of pediatric faculty and residents at the University of California, Davis; Stanford University; and the University of California, San Francisco, until thematic saturation occurred. Transcripts were analyzed based on Mezirow's and Schon's models of reflection, using the constant comparative method associated with grounded theory. Two investigators independently coded transcripts and reconciled codes to develop themes. All investigators reviewed the codes and developed a final list of themes through consensus. Through iterative discussions, investigators developed a conceptual model of reflection in the clinical setting. RESULTS: Seventeen faculty and 20 residents from three institutions participated in six focus groups. Five themes emerged: triggers of reflection, intrinsic factors, extrinsic factors, timing, and outcome of reflection. Various triggers led to reflection; whether a specific trigger led to reflection depended on intrinsic and extrinsic factors. When reflection occurred, it happened in action or on action. Under optimal conditions, this reflection was goal and action directed and became critical reflection. In other instances, this process resulted in unproductive rumination or acted as an emotional release or supportive therapy. CONCLUSIONS: Participants reflected in clinical settings, but did not always explicitly identify it as reflection or reflect in growth-promoting ways. Strategies to enhance critical reflection include developing knowledge and skills in reflection, providing performance data to inform reflection, creating time and space for safe reflection, and providing mentorship to guide the process.

Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones.

BACKGROUND: Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones. METHODS: All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones. RESULTS: Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency. CONCLUSIONS: Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees.

PURPOSE: Trainee mistreatment remains an important and serious medical education issue. Mistreatment toward trainees by the medical team has been described; mistreatment by patients and families has not. Motivated by discrimination towards a resident by a family in their emergency department, the authors sought to identify strategies for trainees and physicians to respond effectively to mistreatment by patients and families. METHOD: A purposeful sample of pediatric faculty educational leaders was recruited from April-June 2014 at Stanford University. Using a constructivist grounded theory approach, semistructured one-on-one interviews were conducted. Participants were asked to describe how they would respond to clinical scenarios of families discriminating against trainees (involving race, gender, and religion). Interviews were audio-recorded, transcribed, and anonymized. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking. This project was IRB approved. RESULTS: Four themes emerged from interviews with 13 faculty: assess illness acuity, cultivate a therapeutic alliance, depersonalize the event, and ensure a safe learning environment. Participants wanted trainees to feel empowered to remove themselves from care when necessary but acknowledged that removal was not always possible or easy. Nearly all participants agreed that trainee and faculty development was needed. Suggested educational strategies included team debriefing and critical reflection. CONCLUSIONS: Discrimination towards trainees by patients and families is an important issue. As this type of mistreatment cannot be fully prevented, effective preparation is essential. Effective response strategies exist and can be taught to trainees to empower responses that protect learners and preserve patient care.

Health Education for Women and Children: A Community-Engaged Mutual Learning Curriculum for Health Trainees.

INTRODUCTION: Intimate partner violence (IPV) affects the physical and psychological health of survivors and their children; however, to our knowledge, no comprehensive health curriculum exists for this population. As a partnership between a transitional housing program (THP) and an academic medical center, we developed a health education curriculum for female IPV survivors using the principles of community-based participatory research (CBPR). METHODS: After partnering with a community-based organization, and recruiting participants (IPV survivors), the curriculum is then taught by health trainees. The materials needed to facilitate the 10 workshops are provided and include: a facilitator's guide; workshop materials, including PowerPoint slides and handouts; a training guide for a community partner to teach facilitators about IPV; a sample focus group guide for curricular evaluation that aligns with CBPR methodologies; a sample time line for curricular implementation; and CBPR resources. RESULTS: The curriculum was implemented for two 9-month periods between September 2014 and June 2016. During the first session, 80% of women attended at least one workshop and during the second session, 65% of women did the same. Participants and staff at the THP found the curriculum engaging and requested that it be implemented yearly. DISCUSSION: The community-academic partnership offered prehealth and health trainees the opportunity to learn effective methods of delivering health education and to understand some of the challenges associated with surviving IPV. Such education can be provided to trainees at any stage and across multiple specialties (e.g., medical, nursing, public health, or social work). There is potential to replicate this mutual learning curriculum in a wide variety of other settings serving mothers and children.

Caring for Children With Medical Complexity: Challenges and Educational Opportunities Identified by Pediatric Residents.

OBJECTIVE: High-quality care for children with medical complexity (CMC) is in its infancy. Residents have the opportunity to view care for CMC with a fresh perspective that is informed by their work across diverse health care settings and significant time spent at the bedside. This study aimed to identify the challenges and potential solutions for complex care delivery and education from their perspectives. METHODS: We conducted three 60-minute focus groups with a purposeful sample of residents and recent graduates at a US tertiary-care medical center. Data were transcribed verbatim, and themes were identified using an iterative approach and modified grounded theory. RESULTS: Sixteen participants identified 4 major challenges to caring for CMC: 1) lack of care coordination; 2) complex technology management; 3) patients' pervasive psychosocial needs; and 4) lack of effective health care provider training. Participants identified 3 solutions: 1) greater integration of primary care providers; 2) attention to psychosocial needs through shared decision making; and 3) integration of longitudinal patient relationships into provider training. We found that residents who experienced longitudinal relationships with CMC felt more efficacious and better equipped to handle challenges of caring for CMC as a result of their broader understanding of patients' priorities and of their role as providers. CONCLUSIONS: Residents recognize important challenges and offer thoughtful solutions to caring for CMC. Although multiple solutions exist, formal integration of longitudinal patient experiences into residency training may better prepare residents to understand patient priorities and identify when their own attitudinal changes can guide them into more efficacious roles as providers.