Learner Levels of Supervision Across the Continuum of Pediatrics Training.

PURPOSE: To describe trajectories in level of supervision ratings for linked entrustable professional activities (EPAs) among pediatric learners in medical school, residency, fellowship. METHOD: The authors performed secondary analyses of 3 linked datasets of level of supervision ratings for the Core EPAs for Entering Residency, the General Pediatrics EPAs, and the Subspecialty Pediatrics EPAs. After identifying 9 activities in common across training stages and aligning the level of entrustment-supervision scales across the datasets, piecewise ordinal and linear mixed effects models were fitted to characterize trajectories of supervision ratings. RESULTS: Within each training period, learners were rated as needing less supervision over time in each activity. When transitioning from medical school to residency or during the first year of residency, learners were rated as needing greater supervision in activities related to patient management, teamwork, emergent care, and public health/QI than in earlier periods. When transitioning from residency to fellowship, learners were always rated as needing greater supervision than they had been accorded at the end of residency and sometimes even more than they had been accorded at the start of residency. CONCLUSIONS: Although development over training is often imagined as continuous and monotonically increasing competence, this study provides empirical evidence supporting the idea that entrustment is a set of discrete decisions. The relaxation of supervision in training is not a linear process. Even with a seamless curriculum, supervision is tightly bound to the training setting. Several explanations for these findings are discussed.

Contraception and Adolescent Males: An Opportunity for Providers.

PURPOSE: To examine young men's awareness of emergency contraception (EC) and its association with their contraceptive decision-making contributions within a relationship. METHODS: A convenience sample of English-speaking male patients aged 13-24 years were surveyed regarding their childbearing intentions, contraceptive awareness (including EC), perceived contraceptive knowledge, and communication about birth control with providers and within a relationship. RESULTS: An ethnically diverse sample of adolescent males was recruited with a mean age of 18.9 years. Most had previously been sexually active (75%) and felt it was important to avoid pregnancy (84%) and 61% reported ever having spoken to a health care provider about birth control (other than condoms), but only 42% had heard of EC. Participants who had heard of EC were more likely to have spoken to a health care provider about contraception in the past (51.5% vs. 29.8%; p = .050), to feel they should participate in contraceptive decisions in a relationship (97.4% vs. 76.5%; p = .006), and to have discussed contraception with a partner (76.9% vs. 29.2%; p < .001). CONCLUSIONS: Counseling young men about EC, as well as other methods of birth control, may empower them to become actively involved in contraceptive decisions within a relationship if they do not desire fatherhood.

Trends in illness severity and length of stay in inner-city adolescents hospitalized for pelvic inflammatory disease.

BACKGROUND: In 1998, the Centers for Disease Control and Prevention (CDC) changed their guidelines for treatment of adolescents with pelvic inflammatory disease (PID), no longer recommending hospitalization of all teenagers. STUDY OBJECTIVES: (1) To determine the proportion of adolescents with PID who were admitted for failed outpatient treatment after the CDC guideline change. (2) To determine if adolescents admitted for PID after the guideline change needed longer hospital stays and/or were more likely to be "very ill" [as measured by inflammation markers, e.g. fever] or to have tubo-ovarian abscess (TOA) than those admitted before the change. DESIGN: Retrospective chart review SETTING/PARTICIPANTS: All 12-21-year-old females with the diagnosis of PID admitted to an adolescent inpatient unit in an inner-city teaching hospital during a two-year period before [T1=1995-1997 (54 cases)] and after [T2=1998-2000 (91 cases)] the CDC guideline change. INTERVENTIONS: None MAIN OUTCOME MEASURES: Reason for admission (failed outpatient treatment; TOA; or admission at the time of diagnosis of PID); clinical toxicity at admission, and length of hospital stay (LOS). RESULTS: During T2, 22% of PID admissions were for failure of outpatient therapy. However, those admitted after failure of outpatient therapy (n=20) in T2 were less likely to be "very ill" than those who were admitted at the time of PID diagnosis in either T1 or T2 (n=123) [RR:0.30; 95% CI:0.09-0.94]. Mean LOS for females admitted to the adolescent unit with all diagnoses other than PID did not change between T1 and T2 but mean LOS for those diagnosed with PID decreased significantly from 6.3 +/- 3.7 days to 4.7 +/- 2.7 days, respectively (P = 0.002). LOS for PID was longer for younger (<16 years; 8.20 +/- 4.5 days) than older (> or =16 years; 5.0 +/- 2.8 days) girls (P = 0.02) and for adolescents with TOA (7.9 +/- 5.0 days) than for those without (5.3 +/- 2.9 days) (P = 0.05). CONCLUSION: At our medical center, after the CDC guideline change many adolescents with PID were admitted because of failure of outpatient therapy but they were not sicker than those admitted at the time of diagnosis and overall LOS for PID was shorter. These findings are reassuring because they suggest that an initial trial of outpatient therapy for PID is unlikely to harm adolescents and may lead to significant cost savings.