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.

Effect of gastrojejunal feedings on visits and costs in children with neurologic impairment.

OBJECTIVE: The objective of the present study was to determine the effect of gastrojejunal tube (GJT) feedings in children with neurologic impairment (NI) on gastroesophageal reflux disease (GERD)- and/or dysfunctional swallowing-related visits and their associated costs. METHODS: The present study is a retrospective cohort study of children with NI and GERD who underwent GJT placement at the study hospital from December 1999 to October 2006. Visits (emergency department, radiology, and hospitalizations) were reviewed from the time of birth until 1 year following GJT placement and classified as either not GERD and/or dysfunctional swallowing related or GERD and/or dysfunctional swallowing related (eg, pneumonias). Incident rate ratios (IRRs) were calculated by dividing the post-GJT visit rate by the pre-GJT visit rate. Other outcomes included associated costs, fundoplications, and deaths. RESULTS: Thirty-three patients met inclusion criteria. The IRR for total visits was 1.78 (95% confidence interval [CI] 1.12-2.81) and for GERD- and/or dysfunctional swallowing-related visits 2.88 (95% CI 1.68-4.94). Feeding tube-related visits (IRR 5.36, 95% CI 2.73-10.51) accounted for the majority. GERD- and/or dysfunctional swallowing-related costs per child per year were low overall, with no difference from pre-GJT versus post-GJT placement ($1851 vs $4601, P = 0.89). Seven (21%) children underwent Nissen fundoplication and 4 (12%) died within 1 year of GJT placement. Two deaths involved jejunal perforation. CONCLUSIONS: Children with NI and GERD who are treated with GJT feedings have significantly more GERD- and/or dysfunctional swallowing-related visits in the following year. The majority of these visits are because of the procedural complications, which are inexpensive. There is, however, mortality associated with the GJT and some children proceed to a fundoplication.

Visual diagnosis: 2-month-old girl with left eye swelling, profuse tearing.

Nasolacrimal duct (NLD) obstruction is the most common cause of persistent tearing in a child younger than 1 year. Other possible causes include congenital eyelid abnormalities, chemical irritation, trauma, occult foreign body, congenital or early-onset glaucoma, and conjunctivitis. • In addition to NLD obstruction signs, dacryocystoceles also present with swelling over the nasolacrimal sac. The swelling often has a bluish discoloration. • Management of NLD obstruction requires a conservative approach with observation and nasolacrimal massage because spontaneous resolution occurs in approximately 90% by age 6 months and in more than 99% by age 12 months. Referral to an ophthalmologist for children with persistent symptoms should be deferred until at least ages 6 to 9 months. • Because of the high risk of complications with dacryocystoceles, especially infection, these patients require urgent ophthalmology referral. • Acute dacryocystitis presents with erythema, swelling, warmth, and tenderness of the lacrimal sac. The infection must be identified and treated early to prevent complications, such as periorbital and orbital cellulitis, meningitis, brain abscess, and sepsis.

Mitigating "Educational Groundhog Day" - The Role of Learner Handoffs Within Clinical Rotations: A Survey of Pediatric Educational Leaders.

BACKGROUND: Medical students decry frequent changes in faculty supervision, leading to the experience of "educational groundhog day." The discontinuity in supervision, cursory relationships, and uncoordinated feedback impede students' skill acquisition and delay entrustment decisions. Whereas patient handoff bundles are common, little is known about similarly structured approaches to learner handoffs (LHs). OBJECTIVE: To describe current LH procedures and practices within pediatric clerkships and subinternships and to gauge interest in a future LH bundle. METHODS: Nine items included in the 2016 Council on Medical Student Education in Pediatrics annual member survey were analyzed using mixed-methods. RESULTS: The response rates were 66% (101 of 152) and 40% (165 of 411) for institutions and individuals, respectively. After limiting data to complete responses to programs with traditional block rotations, 54% of individual respondents (76 of 141) identified as inpatient faculty and about a quarter endorsed providing LHs. Inpatient faculty most commonly supervise medical students for 5 to 7 days. Most endorsed needing 1 to 3 days to determine a student's baseline performance and 5 days or more to make entrustment decisions. Three-quarters of inpatient faculty endorsed interest in LHs, while fewer than 16% of course directors currently provide LH expectations. Four themes emerged: instrument features, stakeholder buy-in, impact, and utility. CONCLUSIONS: Typical inpatient faculty service days approximate the time required for making entrustment decisions about clinical students. While most inpatient faculty desire a LH bundle for use within a clinical rotation, few institutions and faculty currently use LHs. LHs could accelerate entrustment decisions by allowing coordinated feedback that might hasten learner clinical-skill development.

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.

Current Practices and Perspectives on Peer Observation and Feedback: A National Survey.

OBJECTIVE: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF. METHODS: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States. RESULTS: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%). CONCLUSIONS: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs.

Efficacy of a Web-Based Oral Case Presentation Instruction Module: Multicenter Randomized Controlled Trial.

OBJECTIVE: Effective self-directed educational tools are invaluable. Our objective was to determine whether a self-directed, web-based oral case presentation module would improve medical students' oral case presentations compared to usual curriculum, and with similar efficacy as structured oral presentation faculty feedback sessions. METHODS: We conducted a pragmatic multicenter cluster randomized controlled trial among medical students rotating in pediatric clerkships at 7 US medical schools. In the clerkship's first 14 days, subjects were instructed to complete an online Computer-Assisted Learning in Pediatrics Program (CLIPP) oral case presentation module, an in-person faculty-led case presentation feedback session, or neither (control). At the clerkship's end, evaluators blinded to intervention status rated the quality of students' oral case presentations on a 10-point scale. We conducted intention-to-treat multivariable analyses clustered on clerkship block. RESULTS: Study participants included 256 CLIPP (32.5%), 263 feedback (33.3%), and 270 control (34.2%) subjects. Only 51.1% of CLIPP subjects completed the assigned presentation module, while 98.5% of feedback subjects participated in presentation feedback sessions. Compared to controls, oral presentation quality was significantly higher in the feedback group (adjusted difference in mean quality, 0.28; 95% confidence interval, 0.08, 0.49) and trended toward being significantly higher in the CLIPP group (0.19; 95% confidence interval, -0.006, 0.38). The quality of presentations in the CLIPP and feedback groups was not significantly different (-0.10; 95% confidence interval, -0.31, 0.11). CONCLUSIONS: The quality of oral case presentations delivered by students randomized to complete the CLIPP module did not differ from faculty-led presentation feedback sessions and was not statistically superior to control.

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.

Shift Schedules and Intern Work Hours, Patient Numbers, Conference Attendance, and Sleep at a Single Pediatric Residency Program.

OBJECTIVE: The effects of 2011 Accreditation Council on Graduate Medical Education (ACGME) duty hour standards on intern work hours, patient load, conference attendance, and sleep have not been fully determined. We prospectively compared intern work hours, patient numbers, conference attendance, sleep duration, pattern, and quality in a 2011 ACGME duty hour-compliant shift schedule with a 2003 ACGME duty hour-compliant call schedule at a single pediatric residency program. METHODS: Interns were assigned to shift or call schedules during 4 alternate months in the winter of 2010-2011. Work hours, patient numbers, conference attendance, sleep duration, pattern, and quality were tracked. RESULTS: Interns worked significantly fewer hours per week on day (73.2 hours) or night (71.6 hours) shifts than during q4 call (79.6 hours; P < .01). During high census months, shift schedule interns cared for significantly more patients/day (8.1/day shift vs 6.2/call; P < .001) and attended significantly fewer conferences than call schedule interns. Night shift interns slept more hours per 24-hour period than call schedule interns (7.2 ± 0.5 vs 6.3 ± 0.9 hours; P < .05) and had more consistent sleep patterns. CONCLUSIONS: A shift schedule resulted in reduced intern work hours and improved sleep duration and pattern. Although intern didactic conference attendance declined significantly during high census months, opportunities for experiential learning remained robust with unchanged or increased intern patient numbers.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Potential Mimic of Neuroleptic Malignant Syndrome.

BACKGROUND: Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune disorder characterized by behavioral changes, dyskinesia, and autonomic instability. PATIENT DESCRIPTION: We describe a 14-year-old girl who initially presented with acute behavioral changes and seizures and who over a 2-week period developed high fever, tachycardia, and elevated blood pressures. RESULTS: Because she received multiple medications including anticonvulsants and a neuroleptic, our patient was initially diagnosed with neuroleptic malignant syndrome, a disorder characterized by autonomic dysfunction, hyperthermia, muscle rigidity, and mental status changes usually caused by the use of a neuroleptic agent. Further investigation, however, revealed the presence of N-methyl-D-aspartate receptor antibodies and an ovarian teratoma. Symptoms resolved after teratoma resection and intravenous immunoglobulin therapy. CONCLUSION: We propose that anti-N-methyl-D-aspartate receptor encephalitis can cause a paraneoplastic syndrome mimicking neuroleptic malignant syndrome.

The AAP Resilience in the Face of Grief and Loss Curriculum.

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider's responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.