Integrating Discussions on Racism and Health Equity into Clinical Reasoning Conference.

OBJECTIVE: Intentionally discussing racism and health equity in clinical reasoning conference may provide an opportunity to reinforce antiracist praxis. We aimed to understand 1) whether these discussions provide a meaningful opportunity to practice applying an antiracist lens in patient care, 2) the feasibility of implementing these discussions in a clinical reasoning format, and 3) the acceptability to Black, Indigenous, and People of Color (BIPOC) and white residents. METHODS: In 2021, 4 clinical reasoning conference pilot sessions were implemented in a pediatrics residency program. Trained faculty facilitated discussions on mitigating inequity in clinical cases. Residents who attended at least 1 session were invited to participate in focus groups, which were analyzed using grounded theory. RESULTS: Thirty residents attended each pilot session out of the 30 to 35 who had the opportunity to attend. The focus groups included 6 BIPOC and 6 white residents. The discussions offered a meaningful opportunity to practice recognizing and naming racism. Having faculty facilitators made the discussions more feasible. Both groups experienced benefits and wanted the discussions to continue, but BIPOC residents want more engagement from their white peers. CONCLUSIONS: Discussing racism and health equity in clinical reasoning conference was a meaningful, feasible, and acceptable opportunity for antiracist praxis.

Upholding Our PROMISE: Underrepresented in Medicine Pediatric Residents' Perspectives on Interventions to Promote Belonging.

PURPOSE: Underrepresented in medicine (UIM) residents experience challenges during training that threaten their sense of belonging in medicine; therefore, residency programs should intentionally implement interventions to promote belonging. This study explored UIM pediatric residents' perspectives on current residency program measures designed to achieve this goal. METHOD: The authors conducted a secondary qualitative analysis as part of a national cross-sectional study, PROmoting Med-ed Insight into Supportive Environments (PROMISE), which explored pediatric residents' experiences and perspectives during training in relation to their self-identities. A 23-item web-based survey was distributed through the Association of Pediatric Program Directors Longitudinal Educational Research Assessment Network from October 2020 to January 2021. Participants provided free-text responses to the question "What are current measures that promote a sense of belonging for the UIM community in your training program?" The authors used conventional content analysis to code and identify themes in responses from UIM participants. RESULTS: Of the 1,748 residents invited to participate, 931 (53%) residents from 29 programs completed the survey, with 167 (18%) identifying as UIM. Of the 167 UIM residents, 74 (44%) residents from 22 programs responded to the free-text question. The authors coded more than 140 unique free-text responses and identified 7 major themes: (1) critical mass of UIM residents; (2) focused recruitment of UIM residents; (3) social support, including opportunities to build community among UIM residents; (4) mentorship; (5) caring and responsive leadership; (6) education on health disparities, diversity, equity, inclusion, and antiracism; and (7) opportunities to serve, including giving back to the local community and near-peer mentorship of UIM premedical and medical students. CONCLUSIONS: This is the first national study to describe UIM pediatric residents' perspectives on interventions that promote a sense of belonging. Programs should consider implementing these interventions to foster inclusion and belonging among UIM trainees.

Impact of a Multidisciplinary Curriculum Training Students and Residents in Tobacco Cessation Strategies for Adult Caregivers of Children.

Introduction: Children's exposure to secondhand smoke is an underaddressed public health threat. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated framework that trains pediatric providers to screen, counsel, refer to quitlines, and prescribe tobacco cessation medications to adult caregivers of children. Methods: A physician champion at a major urban academic center delivered a longitudinal didactic curriculum of CEASE principles to medical and nurse practitioner students and pediatrics and family medicine residents. At the end of each session, participants completed an anonymous survey measuring changes in self-perceived knowledge, comfort, and familiarity with smoking cessation skills and concepts. Using a separate end-of-year questionnaire, we also surveyed a group of pediatric residents to compare the impact of CEASE training on clinical practice. Finally, we tracked the number of referrals to the state's quitline for the duration of the training. Results: Fifty-two trainees (55% students, 45% residents) responded to the evaluation survey administered immediately following training. There were statistically significant improvements in median scores after CEASE training for comfort in screening, counseling, motivational interviewing, referring to smokers' helplines, and providing caregivers with nicotine replacement therapy (NRT) prescriptions. Fifty-one percent of pediatric residents (41 of 80) responded to the end-of-year survey, which showed statistically significant differences in the number of patients/caregivers offered a referral to California's quitline and prescription of NRT according to completion of CEASE training. Discussion: CEASE training successfully improved the self-efficacy of health professions students and residents in smoking cessation techniques for adult caregivers of children.

Impacts of a Multicenter Medical Education Curriculum for Training Pediatric Residents on Tobacco Cessation for Adult Caregivers of Pediatric Patients.

The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers' ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers' quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients' caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents' attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

The Power of Place: Travel to Explore Structural Racism and Health Disparities.

PROBLEM: Dismantling structural racism is essential to achieving health equity, but there is little guidance for medical educators who wish to teach learners to recognize and confront structural racism. APPROACH: Critical consciousness provides a framework to identify and dismantle structural racism. Using a critical consciousness approach, the authors developed a novel 5-day travel experience to the American South for medical residents and faculty to explore the history and legacy of structural racism and the Civil Rights Movement. The purpose of the travel was to examine the connection between structural racism, especially anti-Black racism, and health disparities to better address health inequities within the participants' own home environment. Throughout the trip, faculty leaders applied principles of cultural humility and techniques from critical pedagogy, including recognizing the value of everyone in the room, creating cognitive disequilibrium, and promoting authentic dialogue. OUTCOMES: End-of-week surveys revealed that the trip was well received. Organizers learned important lessons related to faculty and resident dynamics, race-based affinity group meetings, and the respectful use of stories as a tool for learning. Post-trip surveys at 1, 6, and 12 months revealed 3 major themes: participants experienced (1) transformed understanding of systemic racism, (2) increased motivation and bravery to act when witnessing interpersonal and structural racism, and (3) increased practice of cultural humility. NEXT STEPS: Cultural humility and critical pedagogy can be used with travel to support learners in recognizing and confronting structural racism. The application of such techniques should be explored in local learning environments to foster commitment and action toward dismantling structural racism. In teaching structural racism, medical educators must be willing to consider new ways of teaching and learning.

Improving Diversity in Pediatric Residency Selection: Using an Equity Framework to Implement Holistic Review.

BACKGROUND: Many programs struggle to recruit, select, and match a diverse class of residents, and the most effective strategies for holistic review of applications to enhance diversity are not clear. OBJECTIVE: We determined if holistic pediatric residency application review guided by frameworks that assess for bias along structural, interpersonal, and individual levels would increase the number of matched residents from racial and ethnic groups that are underrepresented in medicine (UiM). METHODS: Between 2017 and 2020, University of California San Francisco Pediatrics Department identified structural, interpersonal, and individual biases in existing selection processes and developed mitigation strategies in each area. Interventions included creating a shared mental model of desirable qualities in residents, employing a new scoring rubric, intentional inclusion of UiM faculty and trainees in the selection process, and requiring anti-bias training for everyone involved with recruitment and selection. RESULTS: Since implementing these changes, the percentage of entering interns who self-identify as UIM increased from 11% in 2015 to 45% (OR 6.8, P = .008) in 2019 and to 35% (OR 4.6, P = .035) in 2020. CONCLUSIONS: Using an equity framework to guide implementation of a pediatric residency program's holistic review of applications increased the numbers of matched UiM residents over a 3-year period.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach.

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Avoiding the Virtual Pitfall: Identifying and Mitigating Biases in Graduate Medical Education Videoconference Interviews.

Public health concerns related to the COVID-19 pandemic are leading many residency and fellowship programs to transition from in-person to videoconference interviews (VCIs). The magnitude and speed of the shift to VCIs, the lack of existing research around bias and VCIs, and the underlying stress on all involved related to the pandemic put programs at risk of implementing virtual interviews without fully exploring their implications for diversity and equity. VCIs can promote diversity efforts by reducing the need for travel, making interviews more convenient and cost effective for applicants. However, VCIs may also introduce new biases and amplify existing biases in recruitment. VCIs introduce a dependence on technology to conduct the interview process, which may amplify systemic inequities in access to broadband internet and high-quality hardware. Communication delays due to technology challenges may negatively affect interview scores. Additionally, users experience increased cognitive load when participating in videoconferences, which can activate implicit biases. Exposure to cues in the interviewee's personal living situation previously unavailable to interviewers may lead to unconscious assumptions by interviewers, which may also influence scoring. Graduate medical education programs committed to maintaining equitable recruitment processes must be able to recognize potential biases in VCIs and implement strategies to mitigate them. This article identifies some of the biases VCIs can introduce to the recruitment process and offers strategies for programs to mitigate them. These include making interviewers aware of potential technology-based inequities, encouraging interviewers to minimize multitasking, and offering guidance on use of standardized backgrounds. The authors also recognize the limitations of offering behavioral strategies to mitigate systemic inequities and suggest that structural changes are needed to ensure equitable access to technology.

Addressing Environmental Smoke Exposure During Pediatric Hospitalization: Attitudes and Practices of Pediatric Nurses Versus Respiratory Therapists.

BACKGROUND: Tobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting. METHODS: An online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded. RESULTS: A total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002). CONCLUSIONS: Compared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Motivational Interviewing: A High-Yield Interactive Session for Medical Trainees and Professionals to Help Tobacco Users Quit.

Introduction: Motivational interviewing (MI) is a collaborative patient-focused counseling technique that is effective in promoting smoking cessation but is not consistently taught/practiced in training. Methods: This training session was implemented in a pediatric residency training program and also given four times to pediatric practitioners as part of a 2-day tobacco training sponsored by the American Academy of Pediatrics (AAP). Pediatric residents (N = 33) participated in a 1-hour interactive session focused on addressing tobacco. Knowledge was assessed with pre- and 6-month postsurveys. Retention of skills was evaluated between 6 and 9 months posttraining by resident performance on two scenarios with standardized patients, which was scored utilizing the Behavior Change Counseling Index (BECCI), by two MI-trained physicians. AAP trainees (N = 115) participated in tobacco trainings with a session dedicated to MI; sessions were evaluated by pre- and posttests. Results: Residents who completed the session (n = 12) performed significantly better on eight of 10 items of the BECCI and on the overall BECCI score (p < .001) compared with those who had not completed the session (n = 12). Feedback on AAP training sessions (N = 115) indicated that practitioners felt able to perform MI and incorporate MI into practice. The percentage of trainees who felt comfortable counseling about tobacco doubled from pre- to posttraining. Discussion: A hands-on MI training session provided pediatric residents and practicing clinicians with knowledge and skills to address tobacco use with patients/families. The session is easily incorporated into different training environments.

Tobacco Use as a Health Disparity: What Can Pediatric Clinicians Do?

Tobacco use is a global health crisis, and has a tremendous and negative impact on health and wellbeing. Tobacco use disproportionately affects members of vulnerable populations, and by acting on multiple socioecological levels, serves to perpetuate and reinforce cycles of poverty. Members of the pediatric medical community can play a key role in interrupting cycles of tobacco use. Providers can serve as powerful allies to vulnerable communities by treating tobacco use in caregivers, counseling youth against using tobacco products, protecting children from the impact of secondhand smoke exposure, and advocating for economic, social, and health policies to disrupt intergenerational smoking.

Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.

BACKGROUND: Asthma exacerbations occur frequently despite the regular use of asthma-controller therapies, such as inhaled glucocorticoids. Clinicians commonly increase the doses of inhaled glucocorticoids at early signs of loss of asthma control. However, data on the safety and efficacy of this strategy in children are limited. METHODS: We studied 254 children, 5 to 11 years of age, who had mild-to-moderate persistent asthma and had had at least one asthma exacerbation treated with systemic glucocorticoids in the previous year. Children were treated for 48 weeks with maintenance low-dose inhaled glucocorticoids (fluticasone propionate at a dose of 44 µg per inhalation, two inhalations twice daily) and were randomly assigned to either continue the same dose (low-dose group) or use a quintupled dose (high-dose group; fluticasone at a dose of 220 µg per inhalation, two inhalations twice daily) for 7 days at the early signs of loss of asthma control ("yellow zone"). Treatment was provided in a double-blind fashion. The primary outcome was the rate of severe asthma exacerbations treated with systemic glucocorticoids. RESULTS: The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups (0.48 exacerbations per year in the high-dose group and 0.37 exacerbations per year in the low-dose group; relative rate, 1.3; 95% confidence interval, 0.8 to 2.1; P=0.30). The time to the first exacerbation, the rate of treatment failure, symptom scores, and albuterol use during yellow-zone episodes did not differ significantly between groups. The total glucocorticoid exposure was 16% higher in the high-dose group than in the low-dose group. The difference in linear growth between the high-dose group and the low-dose group was -0.23 cm per year (P=0.06). CONCLUSIONS: In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129 .).

Individualized therapy for persistent asthma in young children.

BACKGROUND: Phenotypic presentations in young children with asthma are varied and might contribute to differential responses to asthma controller medications. METHODS: The Individualized Therapy for Asthma in Toddlers study was a multicenter, randomized, double-blind, double-dummy clinical trial in children aged 12 to 59 months (n = 300) with asthma necessitating treatment with daily controller (Step 2) therapy. Participants completed a 2- to 8-week run-in period followed by 3 crossover periods with daily inhaled corticosteroids (ICSs), daily leukotriene receptor antagonists, and as-needed ICS treatment coadministered with albuterol. The primary outcome was differential response to asthma medication based on a composite measure of asthma control. The primary analysis involved 2 stages: determination of differential response and assessment of whether 3 prespecified features (aeroallergen sensitization, previous exacerbations, and sex) predicted a differential response. RESULTS: Seventy-four percent (170/230) of children with analyzable data had a differential response to the 3 treatment strategies. Within differential responders, the probability of best response was highest for a daily ICS and was predicted by aeroallergen sensitization but not exacerbation history or sex. The probability of best response to daily ICS was further increased in children with both aeroallergen sensitization and blood eosinophil counts of 300/µL or greater. In these children daily ICS use was associated with more asthma control days and fewer exacerbations compared with the other treatments. CONCLUSIONS: In young children with asthma necessitating Step 2 treatment, phenotyping with aeroallergen sensitization and blood eosinophil counts is useful for guiding treatment selection and identifies children with a high exacerbation probability for whom treatment with a daily ICS is beneficial despite possible risks of growth suppression.

Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma.

BACKGROUND: Studies have suggested an association between frequent acetaminophen use and asthma-related complications among children, leading some physicians to recommend that acetaminophen be avoided in children with asthma; however, appropriately designed trials evaluating this association in children are lacking. METHODS: In a multicenter, prospective, randomized, double-blind, parallel-group trial, we enrolled 300 children (age range, 12 to 59 months) with mild persistent asthma and assigned them to receive either acetaminophen or ibuprofen when needed for the alleviation of fever or pain over the course of 48 weeks. The primary outcome was the number of asthma exacerbations that led to treatment with systemic glucocorticoids. Children in both groups received standardized asthma-controller therapies that were used in a simultaneous, factorially linked trial. RESULTS: Participants received a median of 5.5 doses (interquartile range, 1.0 to 15.0) of trial medication; there was no significant between-group difference in the median number of doses received (P=0.47). The number of asthma exacerbations did not differ significantly between the two groups, with a mean of 0.81 per participant with acetaminophen and 0.87 per participant with ibuprofen over 46 weeks of follow-up (relative rate of asthma exacerbations in the acetaminophen group vs. the ibuprofen group, 0.94; 95% confidence interval, 0.69 to 1.28; P=0.67). In the acetaminophen group, 49% of participants had at least one asthma exacerbation and 21% had at least two, as compared with 47% and 24%, respectively, in the ibuprofen group. Similarly, no significant differences were detected between acetaminophen and ibuprofen with respect to the percentage of asthma-control days (85.8% and 86.8%, respectively; P=0.50), use of an albuterol rescue inhaler (2.8 and 3.0 inhalations per week, respectively; P=0.69), unscheduled health care utilization for asthma (0.75 and 0.76 episodes per participant, respectively; P=0.94), or adverse events. CONCLUSIONS: Among young children with mild persistent asthma, as-needed use of acetaminophen was not shown to be associated with a higher incidence of asthma exacerbations or worse asthma control than was as-needed use of ibuprofen. (Funded by the National Institutes of Health; AVICA ClinicalTrials.gov number, NCT01606319.).

Safety and Immunogenicity of Sequential Rotavirus Vaccine Schedules.

BACKGROUND AND OBJECTIVES: Although both licensed rotavirus vaccines are safe and effective, it is often not possible to complete the schedule by using the same vaccine formulation. The goal of this study was to investigate the noninferiority of the immune responses to the 2 licensed rotavirus vaccines when administered as a mixed schedule compared with administering a single vaccine formulation alone. METHODS: Randomized, multicenter, open-label study. Healthy infants (6-14 weeks of age) were randomized to receive rotavirus vaccines in 1 of 5 different schedules (2 using a single vaccine for all doses, and 3 using mixed schedules). The group receiving only the monovalent rotavirus vaccine received 2 doses of vaccine and the other 4 groups received 3 doses of vaccine. Serum for immunogenicity testing was obtained 1 month after the last vaccine dose and the proportion of seropositive children (rotavirus immunoglobulin A ≥20 U/mL) were compared in all the vaccine groups. RESULTS: Between March 2011 and September 2013, 1393 children were enrolled and randomized. Immune responses to all the sequential mixed vaccine schedules were shown to be noninferior when compared with the 2 single vaccine reference groups. The proportion of children seropositive to at least 1 vaccine antigen at 1 month after vaccination ranged from 77% to 96%, and was not significantly different among all the study groups. All schedules were well tolerated. CONCLUSIONS: Mixed schedules are safe and induced comparable immune responses when compared with the licensed rotavirus vaccines given alone.