'Humility, Concern, Respect': A Qualitative Study Exploring Parent Perspectives on a Pediatrician's Role in Addressing Racism.

OBJECTIVE: To explore racially minoritized families' perceptions on how, and if, physicians should address children's racial identity and concepts of racism within clinical settings. STUDY DESIGN: Parents of racially minoritized children, ages 5 through 18, were interviewed to explore experiences with racial identity formation, discrimination, and the extent to which they wanted pediatricians to address these topics. Children were included at the discretion of their parents. Interviews were transcribed, coded, and analyzed through a critical race theory lens based in constructivist grounded theory. RESULTS: Parents encouraged their children to embrace their racial identities but also wanted to shield them from negative experiences of racism to preserve identity safety. Parents felt pediatricians should address racial issues in a manner specific to their child's situation. Thoughtful inclusion of race-related questions, whether in discussion or on questionnaires, is essential to prevent tension in a therapeutic relationship. There was no consensus on the use of preclinical screening. Instead, families highlighted the importance of embracing humility, trust, and respect. CONCLUSIONS: Participant families have preferences for approaches to address the effects of racism on their children's health. Pediatricians should understand the importance of identity safety and approach their discussions with cultural humility, which includes self-reflection, empathy, active listening, and flexible negotiation. Above all, pediatricians need to create a safe environment for appropriate discussion of these issues.

'The program director's word it's stronger than the word of God': Epistemic injustice revealed through narratives of remediated graduate medical education residents.

BACKGROUND: Though graduate medical education (GME) residency training provides positive experiences for many trainees, it may also result in major stressors and negative experiences, particularly for those requiring remediation. Residents requiring remediation may experience feelings of dismay, shame and guilt that can negatively affect their training, self-efficacy and their medical careers. Power differentials between educators and residents may set the stage for epistemic injustice, which is injustice resulting from the silencing or dismissing a speaker based on identity prejudice. This can lead to decreased willingness of trainees to engage with learning. There is a paucity of literature that explores GME experiences of remediation from the resident perspective. OBJECTIVE: To synthesise the narratives of physician experiences of remediation during residency through the lens of epistemic injustice. METHODS: Between January and July 2022, we interviewed US physicians who self-identified as having experienced remediation during residency. They shared events that led to remediation, personal perspectives and emotions about the process and resulting outcomes. Interviews were analysed using narrative analysis with attention to instances of epistemic injustice. RESULTS: We interviewed 10 participants from diverse backgrounds, specialties and institutions. All participants described contextual factors that likely contributed to their remediation: (1) previous academic difficulty/nontraditional path into medicine, (2) medical disability or (3) minoritised race, gender or sexual identity. Participants felt that these backgrounds made them more vulnerable in their programmes despite attempts to express their needs. Participants reported instances of deflated credibility and epistemic injustices with important effects. CONCLUSIONS: Participant narratives highlighted that deep power and epistemic imbalances between learners and educators can imperil GME trainees' psychological safety, resulting in instances of professional and personal harm. Our study suggests applying an existing framework to help programme directors (PDs) approach remediation with epistemic humility.

A Multimodal, Resident-led Newborn Emergencies Night Curriculum.

INTRODUCTION: Following graduate medical education duty hour reform, many programs have migrated to a night float model to achieve duty hour compliance. This has led to increased focus on optimizing nighttime education. A 2018 internal program evaluation of the newborn night rotation revealed that most pediatric residents received no feedback and perceived little didactic education during their four-week, night float rotation. One hundred percent of resident respondents were interested in increased feedback, didactics, and procedural opportunities. Our objective was to develop a newborn night curriculum to ensure timely formative feedback, enhance trainee didactic experience, and guide formal education. MATERIALS AND METHODS: A multimodal curriculum was designed to include senior resident-led, case-based scenarios, a pre- and post-test, a pre- and post-confidence assessment, a focused procedure "passport," weekly feedback sessions, and simulation cases. The San Antonio Uniformed Services Health Education Consortium implemented the curriculum starting from July 2019. RESULTS: Thirty-one trainees completed the curriculum in over 15 months. There was a 100% pre- and post-test completion rate. Test scores rose from an average of 69% to 94% (25% increase, P < .0001) for interns and an average of 84% to 97% (13% increase, P < .0001) for third-year residents (PGY-3s). When averaged across domains assessed, intern confidence rose by 1.2 points and PGY-3 confidence rose by 0.7 points on a 5-point Likert scale. One hundred percent of trainees utilized the on-the-spot feedback form to initiate at least one in-person feedback session. CONCLUSIONS: As resident schedules evolve, there is an increased need for focused didactics during the night shift. The results and feedback from this resident-led and multimodal curriculum suggest that it is a valuable tool to improve knowledge and confidence for future pediatricians.

Development of Pulmonary Hypertension During Treatment with Diazoxide: A Case Series and Literature Review.

Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infancy. The mainstay of medical management for CHI is diazoxide. Diazoxide inhibits insulin release from the pancreas, but also causes smooth muscle relaxation and fluid retention so it is typically given with chlorothiazide. In July 2015, the FDA issued a drug safety communication warning that pulmonary hypertension (PH) had been reported in 11 infants being treated with diazoxide and that the PH resolved with withdrawal of diazoxide. All three of the cases in our hospital were admitted to the neonatal intensive care unit (NICU) for hypoglycemia. All patients received thorough radiologic and laboratory evaluations related to their diagnosis of CHI. All initially improved when diazoxide was initiated. Case 1 and case 3 were discharged from the NICU on diazoxide and chlorothiazide. Case 2 developed pulmonary hypertension while still in the NICU days after an increase in diazoxide dosing. Case 1 presented to the emergency room in respiratory distress shortly after discharge from the NICU with evidence of PH and heart failure. Case 3 presented to the emergency room after 2 weeks at home due to a home blood glucose reading that was low and developed PH and heart failure while an inpatient. Discontinuation of diazoxide led to resolution of all three patients' PH within approximately one week. The experience of our hospital indicates that pulmonary hypertension may be more common than previously thought in infants taking diazoxide. It is unclear if these symptoms develop slowly over time or if there is some other, as yet undescribed, trigger for the pulmonary hypertension. Our hospital's experience adds to the body of evidence and suggests these infants may benefit from more surveillance with echocardiography.