Positive Outcomes of Optimizing Student-Preceptor Continuity in a Traditional Block Clerkship.

PROBLEM: Student-preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student-preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. INTERVENTION: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1-3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5-8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. CONTEXT: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. OUTCOME: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. LESSONS LEARNED: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student-preceptor continuity.

Physicians and Physician Trainees Rarely Identify or Address Overweight/Obesity in Hospitalized Children.

OBJECTIVES: To determine how frequently physicians identify and address overweight/obesity in hospitalized children and to compare physician documentation across training level (medical student, intern, resident, attending). STUDY DESIGN: We conducted a retrospective chart review. Using an administrative database, Centers for Disease Control and Prevention body mass index calculator, and random sampling technique, we identified a study population of 300 children aged 2-18 years with overweight/obesity hospitalized on the general medical service of a tertiary care pediatric hospital. We reviewed admission, progress, and discharge notes to determine how frequently physicians and physician trainees identified (documented in history, physical exam, or assessment) and addressed (documented in hospital or discharge plan) overweight/obesity. RESULTS: Physicians and physician trainees identified overweight/obesity in 8.3% (n = 25) and addressed it in 4% (n = 12) of 300 hospitalized children with overweight/obesity. Interns were most likely to document overweight/obesity in history (8.3% of the 266 patients they followed). Attendings were most likely to document overweight/obesity in physical examination (8.3%), assessment (4%), and plan (4%) of the 300 patients they followed. Medical students were least likely to document overweight/obesity including it in the assessment (0.4%) and plan (0.4%) of the 244 hospitalized children with overweight/obesity they followed. CONCLUSIONS: Physicians and physician trainees rarely identify or address overweight/obesity in hospitalized children. This represents a missed opportunity for both patient care and physician trainee education.

Implementing Emotional Debriefing in Pediatric Clinical Education.

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice.

Self-Directed Rater Training for Pediatric History and Physical Exam Evaluation (P-HAPEE) Rubric, a Validated Written H&P Assessment Tool.

INTRODUCTION: We developed, revised, and implemented self-directed rater training materials in the course of a validity study for a written Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric. METHODS: Core training materials consist of a single-page instruction sheet, sample written history and physical (H&P), and detailed answer key. We iteratively revised the materials based on reviewer comments and pilot testing. Eighteen attending physicians and five senior residents underwent self-directed training, scored 10 H&Ps, and completed a rubric utility survey in the course of the validity study. We have since implemented the P-HAPEE rubric and self-directed rater training in a pediatric clerkship. Based on input from reviewers, study raters, faculty members, and medical student users, we have also developed and implemented additional optional supplemental training materials. RESULTS: Pilot testing indicated that training takes approximately 1 hour. While reviewers endorsed the training format, several suggested having optional supplemental materials available. Nineteen out of 23 volunteer study raters completed the rubric utility survey. All described the rubric as good or very good and indicated strong to very strong interest in continued use. DISCUSSION: The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps and can be implemented using brief, self-directed rater training.

Developing Validity Evidence for the Written Pediatric History and Physical Exam Evaluation Rubric.

OBJECTIVE: The written history and physical examination (H&P) is an underutilized source of medical trainee assessment. The authors describe development and validity evidence for the Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric: a novel tool for evaluating written H&Ps. METHODS: Using an iterative process, the authors drafted, revised, and implemented the 10-item rubric at 3 academic institutions in 2014. Eighteen attending physicians and 5 senior residents each scored 10 third-year medical student H&Ps. Inter-rater reliability (IRR) was determined using intraclass correlation coefficients. Cronbach α was used to report consistency and Spearman rank-order correlations to determine relationships between rubric items. Raters provided a global assessment, recorded time to review and score each H&P, and completed a rubric utility survey. RESULTS: Overall intraclass correlation was 0.85, indicating adequate IRR. Global assessment IRR was 0.89. IRR for low- and high-quality H&Ps was significantly greater than for medium-quality ones but did not differ on the basis of rater category (attending physician vs. senior resident), note format (electronic health record vs nonelectronic), or student diagnostic accuracy. Cronbach α was 0.93. The highest correlation between an individual item and total score was for assessments was 0.84; the highest interitem correlation was between assessment and differential diagnosis (0.78). Mean time to review and score an H&P was 16.3 minutes; residents took significantly longer than attending physicians. All raters described rubric utility as "good" or "very good" and endorsed continued use. CONCLUSIONS: The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps.