A Pilot Study of the Creation and Implementation of a Teaching Development Assessment Tool.

BACKGROUND: The importance of effective clinical teaching skills is well established in the literature. However, reliable tools with validity evidence that are able to measure the development of these skills and can effectively be used by nonphysician raters do not exist. OBJECTIVE: Our initiative had 2 aims: (1) to develop a teaching development assessment tool (TDAT) that allows skill assessment along a continuum, and (2) to determine if trained nonphysicians can assess clinical teachers with this tool. METHODS: We describe the development of the TDAT, including identification of 6 global teaching domains and observable teaching behaviors along a 3-level continuum (novice/beginner, competent/proficient, expert) and an iterative revision process involving local and national content experts. The TDAT was studied with attending physicians during inpatient rounds with trained physician and nonphysician observers over 6 months. RESULTS: The TDAT showed emerging evidence of content, construct, and viable validity (the degree to which an assessment tool is practical, affordable, suitable, evaluable, and helpful in the real world) for the evaluation of attending physicians on inpatient rounds. Moderate to near perfect interrater reliability was seen between physician and nonphysician raters for the domains of promotion of clinical reasoning, control of the learning environment, ability to teach to multiple levels of learners, and provision of feedback. CONCLUSIONS: The TDAT holds potential as a valid and reliable assessment tool for clinical teachers to track the development of each individual's teaching skills along the continuum from early development to mastery.

USPSTF perspective on evidence-based preventive recommendations for children.

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States.

The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements aimed at enhancing the quality of primary care training in the United States.More than 35 contracts and cooperative agreements have been issued by HRSA with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. These activities have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance.The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty. Overall, generalist competencies and education in new content areas have been the distinguishing features of these initiatives. This effort has enhanced not only generalist training but also the general medical education of all students, including future specialists, because so much of the generalist competency agenda is germane to the general medical education mission.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The role of Title VII funding in academic general pediatrics fellowships and leadership.

Since 1979, the Health Resources and Services Administration, Bureau of Health Professionals Title VII, Section 747 (Title VII) programs have been critical to both fellowship and leadership training in academic general pediatrics. Title VII-funded faculty development programs and targeted contract funding have played an important role in training pediatric academic generalist faculty, supporting individual fellowship programs, defining the core elements of such programs, and expanding faculty development to include leadership training. As the major continuing source of external funding for these programs, Title VII has produced documented successful outcomes in all areas in terms of both numbers and accomplishments of trainees. Title VII-funded fellows, as well as the leaders trained, have formed and extended the field of general pediatrics, ultimately improving the health of children, especially in underserved and vulnerable populations.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Strengthening the academic base of general pediatrics fellowship programs: a national program and curriculum development project.

OBJECTIVE: To improve academic general pediatrics (AGP) fellowship programs by 1) developing curriculum guidelines and program standards and 2) creating a process for program review and consultation that might later be used for accreditation of AGP fellowship programs. METHODS: This project of the Ambulatory Pediatric Association (APA) created 4 documents: AGP fellowship program requirements, core curriculum, educational goals and objectives, and a standardized form to describe required program characteristics. Site visits were conducted at 7 volunteer AGP fellowship programs, selected for diversity of content, structure, and location. Evaluations were conducted using a uniform checklist of requirements that combined numerical ratings with a written evaluation summary. Feedback from programs on the review process enabled refinement of the documents. RESULTS: The site visits revealed great variety in emphasis among the 7 programs. In general, faculty were dedicated and capable, and programs showed considerable educational strengths. Typical problems were lack of integration of the program within departmental structures, overburdened faculty, and uncertain funding. Many programs demonstrated suboptimal curriculum planning and weak evaluation methods. Most program leaders felt that the project materials helped to improve the quality of their programs, and 5 of 7 programs expressed willingness to be involved in formal accreditation review in the future. CONCLUSIONS: AGP fellowship programs that volunteered for piloting of an accreditation process were diverse and vital, with rich educational offerings despite a lack of optimal curriculum structure, minimal evaluation, limited faculty resources, and tenuous funding. An APA accreditation process appears to be feasible and may enhance AGP fellowship programs.

Academic general pediatric fellowships: curriculum design and educational goals and objectives.

Academic generalists are unique and important members of the pediatric landscape.(1) Academic general pediatrics (AGP) is not considered a subspecialty, because it adheres to generalist values and embraces a wide range of clinical activities. Nonetheless, academic generalists engage in important scholarly efforts, contribute extensively to the education of new pediatricians, and must be prepared to survive in academia. Academic general pediatric faculty positions are subject to the same appointment and promotion requirements as those of subspecialist faculty.

The status of academic general pediatrics: no longer endangered?

Our study objective was to assess the current state of general academic pediatrics in the United States. A confidential survey of division directors was conducted. At the beginning and end of the survey period, programs were called to verify the director's name. Of 199 divisions surveyed, 119 were returned. The number of physician and nonphysician division faculty has grown from a mean of 12.1 (+/-8.2) and 1.7 (+/-1.8), respectively, 5 years ago to 15.6 (+/-11.7) and 2.1 (+/-2.6). Over a 15- to 18-month period, 21% of programs had a change in division director leadership. Over 90% of divisions rated the clinical care and education missions as "very important," with research and advocacy thus rated by 29% and 50%. Ninety-five percent of divisions have primary responsibility for residency continuity clinics, 51% residency program, and 64% medical student clerkship. The mean number of annual outpatient visits was 29,821 (26,487). Academic general pediatrics divisions have grown and play a large role in clinical care, education, and research at their institutions. There is a need for continued focus on recruitment, fellowship training, faculty development, and leadership development. Although these divisions are now well established, many continue to feel "endangered" because of funding uncertainties in supporting their missions.

The application of social and adult learning theory to training in community pediatrics, social justice, and child advocacy.

Perhaps the greatest challenge we face today in medical education is how to establish a conceptual framework for conveying the context of community pediatrics and issues related to child health equity and social justice to practicing pediatricians and pediatricians in training. This will require a new infrastructure and approach to training to allow pediatricians to think and practice differently. The application of social and adult learning theory to the development and implementation of community pediatrics curricula will be necessary to succeed in these endeavors. In particular, we also will need to understand the educational processes required to motivate adult learners to acquire knowledge, attitudes, and skills outside the context and framework of their previous experiences and perceived professional needs.

Health-related quality of life in urban elementary schoolchildren.

BACKGROUND: Health disparities between children from urban minority backgrounds and children from more affluent backgrounds are well-recognized. Few studies specifically address urban children's perceptions of their health-related quality of life (HRQOL) or the factors that contribute to these perceptions. Since schools are pivotal to children's intellectual, social, and emotional development, school connectedness may be a factor that contributes to their perception of HRQOL. OBJECTIVE: To examine children's perceptions of HRQOL in an elementary school-based population of urban children. METHODS: The study population consisted of 2nd, 3rd, and 5th graders from 6 urban kindergarten to 8th grade schools and their parents. Children completed a survey that included questions on HRQOL and school connectedness. Parents completed a telephone survey that assessed demographics, the child's health, health care usage, and parental health status. Data on school absences and mobility from the computerized school database were linked to survey data. Bivariate analyses were used to evaluate the association between child report of HRQOL and collected variables, including school connectedness. Multivariable linear regression was conducted to identify the factors best predicting HRQOL in these urban children. RESULTS: Of the 1150 eligible students, parent and child survey data were available for 525 (45.6%). Fifty-one percent of students were male and 89% were black. Ninety-four percent of parents were female, 29% were married, and 62% had family incomes below 20,000 dollars per year. The mean total score for HRQOL was 67.2, with a possible range of 0 to 100 (higher scores reflecting better HRQOL). In the multivariable analysis, child grade, the relationship of the " parent" to the child, employment, family income, type/presence of insurance, and school connectedness were significantly associated with the HRQOL total score. CONCLUSIONS: Young urban children self-report low HRQOL scores and do so as early as the 2nd grade. These low scores, which reflect children's own perceptions of impaired psychological and physical health, have potential implications for the success of urban children in their learning environments. The association between HRQOL and school connectedness might suggest that health and educational programs that improve a child's attachment to school could result in improved perceptions of health by urban children.

Urban elementary school personnel's perceptions of student health and student health needs.

OBJECTIVE: To determine the perceptions of school personnel with regard to urban students' health and health needs as part of a planning process for development and implementation of school-linked health services. METHODS: A self-administered, close-ended questionnaire was given to 294 schoolteachers and school staff to assess school personnel perceptions of 1) health needs of students, 2) priority of need for health services or programs delivered on-site or off-site, and 3) selected factors suspected to affect implementation of new school health services. RESULTS: A total of 72% of teachers and 77% of staff completed the survey. The most highly ranked need by school personnel was mental health, followed by violence and anger management and physical abuse and domestic violence. The most commonly requested services on-site and off-site were for physical abuse or domestic violence, mental health, and drug or other substance abuse. Only 40% of teachers and staff rated current health services as excellent or good. A total of 72% of teachers and staff had some level of discomfort with their current responsibilities regarding the health of students. Parental involvement was reported to be quite low, with only 9% of teachers and staff rating it as excellent or good. CONCLUSIONS: he greatest health care need identified by these elementary school personnel was not for management of chronic or acute physical health conditions, but for mental health services and programs to meet the emotional and psychosocial needs of students. When implementing school-linked or school-based mental health services, focus needs to be placed on 3 areas: 1) education of school health and educational personnel regarding common mental health issues, 2) development of systems that improve knowledge of and connection with mental health resources inside and outside the school, and 3) development of systems that improve communication within the school and between the school and parents regarding health services.