Scholarly Activity during Neonatal-Perinatal Medicine Fellowship.

OBJECTIVE: This study aimed to describe scholarly activity training during neonatal-perinatal medicine (NPM) fellowship and factors associated with scholarship productivity. STUDY DESIGN: NPM fellowship program directors (FPDs) were surveyed between March and October 2019, as part of a larger study of all pediatric subspecialty programs, to define barriers, resources, and productivity for fellow scholarly activity. High productivity was defined as >75% of fellows in a program in the last 5 years having a manuscript accepted for publication based on fellowship scholarly work. RESULTS: Fifty-four percent (54/100) of NPM FPDs completed the survey. Nineteen fellowship programs (35%, 19/54) met the definition for high productivity. High productivity in scholarly activity was associated with a greater likelihood of having funds to conduct scholarship (p = 0.011), more protected months dedicated to scholarly activity (p = 0.03), and fellow extramural grant applications (submitted or accepted, p = 0.047). FPDs of productive programs were less likely to report lack of an adequate core research curriculum (p = 0.018), lack of adequate expertise on the fellowship scholarly oversight committee (p = 0.048), and lack of sufficient divisional mentorship (p = 0.048) as barriers to completion of scholarly activity during fellowship. CONCLUSION: Research funding, protected research time, established research mentors, and a research curriculum are associated with higher scholarly activity productivity among NPM fellowship programs. Further investment in these resources may improve scholarly activity productivity during fellowship training. KEY POINTS: · Fellow productivity depends on protected time.. · Inadequate funding impacts fellow productivity.. · Mentorship is important for fellow scholarship.. · A research curriculum impacts research outcomes..

Clinical competency committee perceptions of entrustable professional activities and their value in assessing fellows: A qualitative study of pediatric subspecialty program directors.

OBJECTIVES: To examine the composition and processes of Clinical Competency Committees (CCCs) assigning entrustable professional activity (EPA) levels of supervision for pediatric subspecialty fellows and to examine fellowship program director (FPD) perspectives about using EPAs to determine fellows' graduation readiness. METHODS: A qualitative study was performed using one-on-one interviews with a purposeful sample of pediatric subspecialty FPDs to yield a thematic analysis. Semi-structured interview guides were used for participants who self-identified as EPA users or non-users. Inductive analysis and coding were performed on transcripts until theoretical sufficiency was attained. RESULTS: Twenty-eight FPDs were interviewed. There was significant variability in the composition and processes of CCCs across subspecialties. FPDs felt that CCCs intuitively understand what entrustment means, allowing for ease of application of level of supervision (LOS) scales and consensus. FPDs perceived that EPAs provided a global assessment of fellows and are one tool to determine graduation readiness. CONCLUSIONS: Although there was variability in the makeup and processes of CCCs across subspecialties, FPDs believe EPAs are intuitive and relatively easy to implement. Consensus can be reached easily using EPA-specific LOS scales focusing on entrustment. FPDs desire a better understanding of how EPAs should be used for graduation.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment.

BACKGROUND: Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment. OBJECTIVES: We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale. RESULTS: One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05). CONCLUSIONS: We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Perspectives from the Society for Pediatric Research: advice on sustaining science and mentoring during COVID-19.

The COVID-19 pandemic will leave an indelible mark on the careers of current medical trainees. Given the disruptions to medical education, economic impact on institutions, and the uncertainties around future job prospects, trainees are facing unprecedented challenges. This situation is especially concerning for futures of pediatric physician-scientist trainees, where concerns regarding maintaining the pipeline were well documented prior to the emergence of COVID-19. In this Perspectives article, we leverage the unique expertise of our workgroup to address concerns of physician-scientist trainees and to provide suggestions on how to navigate career trajectories in the post-COVID-19 era. We identified and addressed four major areas of concern: lack of in-person conferences and the associated decrease access to mentors and networking activities, decreased academic productivity, diminished job prospects, and mental health challenges. We also suggest actions for trainees, mentors and educational leaders, and institutions to help support trainees during the pandemic, with a goal of maintaining the pediatric physician-scientist pipeline.

Effect of vitamin D-binding protein genotype on the development of asthma in children.

BACKGROUND: Potential vitamin D-related influences on inflammatory diseases such as asthma are controversial, including the suggestion that vitamin D insufficiency is associated with increased asthma morbidity. Vitamin D-binding protein transports vitamin D metabolites in the circulation. Single nucleotide polymorphisms in the GC gene encoding vitamin D-binding protein are associated with circulating vitamin D metabolite levels in healthy infants and toddlers. OBJECTIVE: To test the hypothesis that GC single nucleotide polymorphisms encoding the D432E and T436K variants predict subsequent development of asthma in healthy children. METHODS: A retrospective medical record review was performed to determine the development of asthma in 776 children in whom GC genotype, vitamin D-binding protein concentration, and circulating 25-hydroxyvitamin D had been determined at 6 to 36 months of age. Demographic and detailed current clinical data were collected and criteria for asthma were recorded. RESULTS: GC genotype was available for 463 subjects. After an initial analysis of all subject data, the analysis was limited to the predominant Hispanic population (72.1%) to minimize potential confounding effects of ethnicity. Asthma was diagnosed in 87 children (26%). Subjects with the GC genotype encoding the ET/ET (Gc1s/Gc1s) variant had lower odds of developing asthma, representing a protective effect compared with subjects with the DT/DT (Gc1f/Gc1f) variant. CONCLUSION: In the Hispanic population of inner-city New Haven, Connecticut, the ET/ET (Gc1s/Gc1s) genotype of vitamin D-binding protein might confer protection against the development of asthma compared with the wild-type genotype DT/DT (Gc1f/Gc1f).

Association between right ventricular dysfunction and restrictive lung disease in childhood cancer survivors as measured by quantitative echocardiography.

BACKGROUND: Restrictive lung disease is a complication in childhood cancer survivors who received lung-toxic chemotherapy and/or thoracic radiation. Left ventricular dysfunction is documented in these survivors, but less is known about right ventricular (RV) function. Quantitative echocardiography may help detect subclinical RV dysfunction. The aim of this study was to assess RV function quantitatively in childhood cancer survivors after lung-toxic therapy. PROCEDURES: We identified records of 33 childhood cancer survivors who (1) were treated with lung-toxic therapy and/or radiation, (2) were cancer-free for ≥ one year after therapy, and (3) had pulmonary function tests and echocardiograms from their most recent follow-up visit. RESULTS: Participants' mean age was 11.6 ± 4.5 years at cancer diagnosis and 23 ± 8.6 years at evaluation. The most common diagnosis was lymphoma/leukemia (n = 27). Twenty-nine subjects had anthracycline exposure. Eleven of the 33 subjects demonstrated restrictive pulmonary impairment (total lung capacity 3.69 ± 1.5 L [69.3 ± 22.4% predicted]). Among quantitative measures of RV function, isovolumetric acceleration (IVA), a measure of contractility, was significantly lower in the group with restrictive lung disease (2.42 ± 0.56 vs. 1.83 ± 0.78 m/sec(2); P < 0.05). There was a trend towards lower tissue Doppler derived S' and tricuspid annular plane systolic excursion in the group with restrictive lung disease. Subjects with restrictive lung disease were found to have ≥ 2 abnormal parameters (P < 0.01). CONCLUSION: IVA may detect early RV dysfunction in childhood cancer survivors with restrictive lung disease. Our findings require confirmation in a larger study population and validation by cardiac MRI.

Quality Improvement Initiative Enhances Outpatient Pediatric Pulmonology Follow-up for Premature Infants with Bronchopulmonary Dysplasia.

Introduction: Bronchopulmonary dysplasia (BPD) is a chronic lung disorder affecting many premature infants. Infants with BPD have higher hospital readmission rates due to respiratory-related morbidity. We aimed to increase the rates of outpatient pulmonary follow-up and attendance of premature babies with moderate and severe BPD to above 85% within 6 months. Methods: We conducted a quality improvement project at Yale New Haven Children's Hospital. Key interventions included developing a BPD clinical pathway integrated into the electronic medical record to assist providers in correctly classifying BPD severity, assigning the appropriate International Classification of Diseases, 10th Revision code (P27.1), and providing standardized treatment options. The outcome measures included correct diagnosis and classification of BPD, the percentage of patients with BPD scheduled for pediatric pulmonology appointments within 45 days, and the percentage attending those appointments. Results: There were 226 patients in our study, including 85 in the baseline period. Correct diagnosis of BPD increased from 49% to 95%, the percentage of scheduled appointments increased from 71.9% to 100%, and the percentage of appointments attended increased from 55.6% to 87.1%. Conclusions: Our quality improvement initiative improved the accuracy of diagnosis, severity classification, and outpatient pulmonary follow-up of children with moderate and severe BPD.

Exploring Factors for Implementation of EPAs in Pediatric Subspecialty Fellowships: A Qualitative Study of Program Directors.

OBJECTIVE: To understand fellowship program directors' (FPDs) perspectives on facilitators and barriers to using entrustable professional activities (EPAs) in pediatric subspecialty training. METHODS: We performed a qualitative study of FPDs, balancing subspecialty, program size, geographic region and current uses of EPAs. A study coordinator conducted 1-on-1 interviews using a semistructured approach to explore EPA use or nonuse and factors supporting or preventing their use. Investigators independently coded transcribed interviews using an inductive approach and the constant comparative method. Group discussion informed code structure development and refinement. Iterative data collection and analysis continued until theoretical sufficiency was achieved, yielding a thematic analysis. RESULTS: Twenty-eight FPDs representing 11 pediatric subspecialties were interviewed, of whom 16 (57%) reported current EPA use. Five major themes emerged: (1) facilitators including the intuitive nature and simple wording of EPAs; (2) barriers such as workload burden and lack of a regulatory requirement; (2) variable knowledge and training surrounding EPAs, leading to differing levels of understanding; (3) limited current use of EPAs, even among self-reported users; and (4) complementary nature of EPAs and milestones. FPDs acknowledged the differing strengths of both EPAs and milestones but sought additional knowledge about the value added by EPAs for assessing trainees, including the impact on outcomes. CONCLUSIONS: Identified themes can inform effective and meaningful EPA implementation strategies: Supporting and educating FPDs, ongoing assessment of the value of EPAs in training, and practical integration with current workflow. Generating additional data and engaging stakeholders is critical for successful implementation for the pediatric subspecialties.

Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process.

BACKGROUND AND OBJECTIVES: Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones. METHODS: We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones. RESULTS: The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%). CONCLUSIONS: Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

Exercise-induced bronchoconstriction and vocal cord dysfunction: two sides of the same coin?

Patients are referred often because of self-reported symptoms of dyspnea and wheeze during exercise. The two common causes of exercise-induced dyspnea are exercise-induced bronchoconstriction (EIB) and vocal cord dysfunction (VCD). It can be extraordinarily difficult to differentiate between the two, especially because they may coexist in the same patient. EIB is caused by bronchial smooth muscle constriction in the lower airways due to the inhalation of dry air or allergens during exercise; it is associated with the release of bronchoconstricting mediators from airway cells. EIB can occur in patients with or without persistent asthma. In contrast, VCD is associated with the paradoxical adduction of the vocal cords, especially during inhalation, which may produce inspiratory stridor. VCD can be solitary or comorbid with asthma and/or EIB. EIB classically is most severe after the cessation of exercise, while VCD typically occurs during exercise and resolves quickly upon exercise cessation. However, history is not adequate to differentiate between EIB and VCD, and appropriate challenge tests and flexible laryngoscopy during exercise are often necessary for diagnosis. This article examines our current understanding of these entities and discusses the mechanism, prevalence, diagnosis, and treatment.

The history of workforce concerns in pediatric pulmonary Medicine.

Children are affected by a broad spectrum of acute and chronic respiratory disorders. The number of children with respiratory disease is increasing, as are the complexity of disease pathophysiology and the management demands on pediatric pulmonologists. Despite slowly increasing numbers of board-certified pediatric pulmonologists, large areas of the country are underserved and there is a perception of an impending workforce crisis. There are multiple reasons for these concerns. A joint effort between the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association was undertaken to address these issues.

Feedback Culture Perceived by Trainees in an Academic Institution: A Mixed Methods Study.

OBJECTIVES: Lack of a well-functioning institutional feedback culture can undermine acquisition of skills essential for high quality patient care. The objective of this study was to assess feedback culture perceived by resident and fellow trainees, utilizing a mixed methods design. METHODS: Pediatric fellows and residents completed an anonymous feedback environment survey consisting of 7 constructs: source credibility, feedback quality, feedback delivery, reinforcing feedback, constructive feedback, source availability, and promotion of feedback seeking, using a 7-point Likert scale. Trainee ratings were compared using two-sided Fisher's exact tests. Multivariable analyses used a linear regression model. For the qualitative study, semistructured interviews of residents were conducted. The constant comparative method was used to incrementally code, categorize data, and derive themes. RESULTS: Fifty-two residents and 21 fellows completed the survey (response rates 65% and 47%, respectively). Scores were more favorable for fellows compared with residents in 6 of 7 feedback constructs (P < .05), including on multivariate analysis. Hispanic ethnicity and female gender were associated with lower scores on source credibility (P = .04) and constructive feedback (P = .03), respectively. Two qualitative themes were identified: expectation of efficiency in patient care compromises the quality and quantity of feedback, and a culture that prioritizes courtesy over candor negatively impacts feedback quality. These themes were more pronounced when residents worked with pediatric subspecialists compared with hospitalists. CONCLUSIONS: We described the feedback culture, which was less favorable in the residency program. The need for efficient patient care and a culture of courtesy adversely impacted the quality of feedback, especially among subspecialists.

Addressing Mistreatment of Providers by Patients and Family Members as a Patient Safety Event.

OBJECTIVE: Mistreatment of health care providers (HCPs) is associated with burnout and lower-quality patient care, but mistreatment by patients and family members is underreported. We hypothesized that an organizational strategy that includes training, safety incident reporting, and a response protocol would increase HCP knowledge, self-efficacy, and reporting of mistreatment. METHODS: In this single-center, serial, cross-sectional study, we sent an anonymous survey to HCPs before and after the intervention at a 213-bed tertiary care university children's hospital between 2018 and 2019. We used multivariable logistic regression to examine the effect of training on the outcomes of interest and whether this association was moderated by staff role. RESULTS: We received 309 baseline surveys from 72 faculty, 191 nurses, and 46 residents, representing 39.1%, 27.1%, and 59.7%, respectively, of eligible HCPs. Verbal threats from patients or family members were reported by 214 (69.5%) HCPs. Offensive behavior was most commonly based on provider age (85, 28.5%), gender (85, 28.5%), ethnicity or race (55, 18.5%), and appearance (43, 14.6%) but varied by role. HCPs who received training had a higher odds of reporting knowledge, self-efficacy, and experiencing offensive behavior. Incident reporting of mistreatment increased threefold after the intervention. CONCLUSIONS: We report an effective organizational approach to address mistreatment of HCPs by patients and family members. Our approach capitalizes on existing patient safety culture and systems that can be adopted by other institutions to address all forms of mistreatment, including those committed by other HCPs.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Fellow Entrustment for the Common Pediatric Subspecialty Entrustable Professional Activities Across Subspecialties.

OBJECTIVE: To determine the relationship between level of supervision (LOS) ratings for the Common Pediatric Subspecialty Entrustable Professional Activities (EPAs) with their associated subcompetency milestones across subspecialties and by fellowship training year. METHODS: Clinical Competency Committees (CCCs) in 14 pediatric subspecialties submitted LOS ratings for 6 Common Subspecialty EPAs and subcompetency milestone levels mapped to these EPAs. We examined associations between these subcompetency milestone levels and LOS ratings across subspecialty training year by fitting per-EPA linear mixed effects models, regressing LOS rating on milestone level and on training year. RESULTS: CCCs from 211 pediatric fellowship programs provided data for 369 first, 336 second, and 331 third year fellows. Mean subcompetency milestone levels increased similarly among subspecialties for most EPAs compared with the reference, Adolescent Medicine. Mean subcompetency milestones mapped to each EPA and mean EPA LOS ratings generally increased by training year across all subspecialties. CONCLUSIONS: Subcompetency milestones levels mapped to each Common Subspecialty EPA and the EPA LOS ratings increase similarly across subspecialties and by training year, providing validity evidence for using EPA LOS to assess pediatric subspecialty trainee performance. This study supports the development of tools to facilitated the CCC evaluation process across all pediatric subspecialties.