What Do Pediatric Subinterns Say About Their Learning and Assessment? A Qualitative Analysis of Individual Learning Plans.

OBJECTIVE: To perform a qualitative content analysis of learning and assessment strategies that pediatric subinterns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning. METHODS: We analyzed ILPs from medical students enrolled in pediatric subinternships at 10 US medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record 3 or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes. RESULTS: Two hundred and four ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in 5 categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students' ability to make and assess progress on their selected learning objectives. CONCLUSIONS: Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessment strategies. The strategies that students identified in this study provide a menu of learning and assessment options for subinterns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment.

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.

Variability in Kawasaki Disease Practice Patterns: A Survey of Hospitalists at Pediatric Hospital Medicine 2017.

OBJECTIVE: To explore practice variations in the care of patients with Kawasaki disease (KD) among pediatric hospitalist physicians (PHPs). METHODS: A 13-item questionnaire was developed by a multi-institutional group of KD experts. The survey was administered via live-audience polling by using smartphone technology during a KD plenary session at the 2017 Pediatric Hospital Medicine National Meeting, and simple descriptive statistics were calculated. RESULTS: Of the 297 session attendees, 90% responded to at least 1 survey question. Approximately three-quarters of respondents identified as PHPs practicing in the United States. The reported length of inpatient monitoring after initial intravenous immunoglobulin (IVIG) therapy demonstrated a wide time distribution (30% 24 hours, 36% 36 hours, and 31% 48 hours). Similarly, PHP identification of the treatment failure interval, indicated by recrudescent fever after IVIG, demonstrated a broad distribution (56% 24 hours, 27% 36 hours, and 16% 48 hours). Furthermore, there was variation in routine consultation with non-PHP subspecialists. In contrast, PHPs reported little variation in their choice of initial and refractory treatment of patients with KD. CONCLUSIONS: In a convenience sample at a national hospitalist meeting, there was variation in reported KD practice patterns, including observation time after initial treatment, time when the recurrence of fever after initial therapy was indicative of nonresponse to IVIG, and routine consultation of non-PHP subspecialists. These results may guide future study of KD practice patterns and inform efforts to improve evidence-based practices in the care of patients with KD.

Collecting Validity Evidence: A Hands-on Workshop for Medical Education Assessment Instruments.

Introduction: There is an increasing call for developing validity evidence in medical education assessment. The literature lacks a practical resource regarding an actual development process. Our workshop teaches how to apply principles of validity evidence to existing assessment instruments and how to develop new instruments that will yield valid data. Methods: The literature, consensus findings of curricula and content experts, and principles of adult learning guided the content and methodology of the workshop. The workshop underwent stringent peer review prior to presentation at one international and three national academic conferences. In the interactive workshop, selected domains of validity evidence were taught with sequential cycles of didactics, demonstration, and deliberate practice with facilitated feedback. An exercise guide steered participants through a stepwise approach. Using Likert-scale items and open-response questions, an evaluation form rated the workshop's effectiveness, captured details of how learners reached the objectives, and determined participants' plans for future work. Results: The workshop demonstrated generalizability with successful implementation in diverse settings. Sixty-five learners, the majority being clinician-educators, completed evaluations. Learners rated the workshop favorably for each prompt. Qualitative comments corroborated the workshop's effectiveness. The active application and facilitated feedback components allowed learners to reflect in real time as to how they were meeting a particular objective. Discussion: This feasible and practical educational intervention fills a literature gap by showing the medical educator how to apply validity evidence to both existing and in-development assessment instruments. Thus, it holds the potential to significantly impact learner and, subsequently, patient outcomes.

Conducting Quantitative Medical Education Research: From Design to Dissemination.

Rigorous medical education research is critical to effectively develop and evaluate the training we provide our learners. Yet many clinical medical educators lack the training and skills needed to conduct high-quality medical education research. We offer guidance on conducting sound quantitative medical education research. Our aim is to equip readers with the key skills and strategies necessary to conduct successful research projects, highlighting new concepts and controversies in the field. We utilize Glassick's criteria for scholarship as a framework to discuss strategies to ensure that the research question of interest is worthy of further study and how to use existing literature and conceptual frameworks to strengthen a research study. Through discussions of the strengths and limitations of commonly used study designs, we expose the reader to particular nuances of these decisions in medical education research and discuss outcomes generally focused on, as well as strategies for determining the significance of consequent findings. We conclude with information on critiquing research findings and preparing results for dissemination to a broad audience. Practical planning worksheets and comprehensive tables illustrating key concepts are provided in order to guide researchers through each step of the process. Medical education research provides wonderful opportunities to improve how we teach our learners, to satisfy our own intellectual curiosity, and ultimately to enhance the care provided to patients.

O processo de recuperação do uso indevido de drogas em igrejas pentecostais Assembleia de Deus / The process of recovery from drug misuse in the Assembly of God Pentecostal church / El proceso de recuperación del uso indebido de drogas en iglesias pentecostales Asamblea de Dios

A literatura tem indicado diversos problemas relacionados ao uso indevido de drogas na sociedade brasileira. Nesse contexto, as instituições religiosas surgem como local de recuperação. Apresentam-se os resultados obtidos por um estudo visando compreender o processo de recuperação do uso indevido de drogas vivido por fiéis de igrejas pentecostais Assembleia de Deus, de uma comunidade popular da cidade do Rio de Janeiro. Trata-se de pesquisa qualitativa, recorrendo a entrevistas semiestruturadas e observação participante. Foram entrevistados dez participantes dessas igrejas que buscaram o local por problemas relacionados ao uso indevido de drogas. Foi feita análise de conteúdo, buscando nexos de sentido nos discursos. Resultados apontam as motivações da igreja ao interessar-se pela recuperação de usuários de drogas, bem como as dos usuários para a busca da igreja, indicando que o processo de recuperação envolve elementos totalizantes e individualizantes.

A variety of drug misuse-related problems in Brazilian society have been described in the literature. Religious institutions have emerged as a place for recovery, within this context. This paper presents the results from a study that aimed to understand the process of recovery from drug misuse experienced by believers at the Assembly of God Pentecostal church, in a low-income community in Rio de Janeiro. The qualitative method was applied, including semi-structured interviews and participative observation. Ten Assembly of God believers, who sought the church due to drug misuse-related problems, were interviewed. Content analysis was performed, to seek linked meanings in their discourse. The results showed the church's motivations in taking an interest in drug- user rehabilitation, and the users' interest in seeking out the church, thus indicating that the recovery process involves both totalizing and individualizing elements.

La literatura ha indicado varios problemas relacionados con el uso indebido de drogas en la sociedad brasileña. Las instituciones religiosas surgen como sitio de recuperación. Son presentados los resultados de un estudio acerca del proceso de recuperación del uso indebido de drogas vivido por fieles de iglesias pentecostales Asamblea de Dios, en una comunidad popular de Río de Janeiro. Se trata de investigación cualitativa mediante entrevistas semi-estructuradas y observación participante. Fueron entrevistados diez participantes de dicha iglesia que buscaban la institución por problemas relacionados con drogas; se realizó el análisis de contenido, buscando nexo de sentido en los discursos. Los resultados sugieren las motivaciones de la iglesia al interesarse por la recuperación de los usuarios de drogas así como las motivaciones de los usuarios al acudir a la iglesia, indicando que el proceso de recuperación involucra elementos individuales y totalizadores.

Pediatric hospitalists' perspectives on the care of children with medical complexity.

OBJECTIVE: The aims of this study were to identify pediatric hospitalists' perceived views of (1) barriers to delivering care to children with medical complexity (CMC) and (2) their preferred model of inpatient health care delivery for CMC. SUBJECTS: American Academy of Pediatrics Section on Hospital Medicine (AAP-SOHM) Listserv subscribers. METHODS: We conducted a cross-sectional survey of subscribers of the AAP-SOHM Listserv using the survey instrument SurveyMonkey®. Our survey was coadministered with a survey on pediatric hospitalist career satisfaction. RESULTS: The most significant barriers to delivering care to CMC were (1) time constraints (89%), (2) inadequate postdischarge resources (75%), and (3) lack of evidence-based guidelines (64%). Although most pediatric hospitalists in an inpatient service currently care for both CMC and non-CMC patients (91%), only 25% perceive this to be the optimal service model for CMC. The majority of hospitalists (56%) believe that CMC are better served by either an inpatient service dedicated to CMC (30%) or comanaged with an inpatient consult service for CMC (26%). CONCLUSIONS: Identifying the perceived barriers to delivering care to CMC can assist pediatric hospitalists to design studies determining if care delivery is affected by these barriers. Most hospitalists care for CMC on the same service as uncomplicated patients, yet over half perceive that a different model of care delivery would better serve the needs of CMC.

O processo de recuperação do uso indevido de drogas em igrejas pentecostais Assembleia de Deus / Recovery process from drug abuse in Pentecostal Assembly of God

Esta dissertação tem como objetivo compreender o processo de recuperação do uso indevido de drogas vivido por fiéis da igreja pentecostal Assembléia de Deus de uma comunidade popular da cidade do Rio de Janeiro. Fez-se uso do método qualitativo, por meio da utilização de entrevistas semi-estruturadas e observação participante, considerando a visão do fenômeno dos indivíduos que estão neste processo. Foram entrevistados em profundidade 10 participantes de igrejas Assembléia de Deus (AD) que buscaram o local por problemas relacionados ao uso indevido de drogas. Observou-se que a busca pelo tratamento religioso decorre do respeito que os sujeitos e a comunidade têm pelos fiéis da AD, do envolvimento dos familiares dos usuários de droga com a igreja a fim de conseguir ajuda para tirá-los desta situação, da busca ativa que a igreja faz dos mesmos para lhes propor um novo estilo de vida e da crise existencial decorrente da perda de controle sobre o uso da droga e de problemas relativos ao tráfico. Foi demonstrado que a igreja faz o trabalho de recuperação do uso indevido de drogas visando à “cura das almas” e não ao tratamento em si, como meio de transformar a sociedade pela transformação de seus indivíduos, “um a um”. Durante o processo de recuperação, o sujeito se identifica com “outros significativos” que lhes oferecem uma estrutura de plausibilidade para que possam aprender um novo modo de interpretar o mundo e de estar nele. O indivíduo afasta-se dos antigos companheiros de droga ou de tráfico e passa a redefinir sua biografia em termos de “antes” e “depois” da conversão. As dificuldades de relacionamento dentro da igreja são apontadas como o maior fator de desmotivação para a permanência neste grupo. A conclusão do estudo é de que tanto a categoria pessoa como indivíduo são utilizadas no processo de recuperação. ...

This thesis aims to understand the recovery process of drug misuse experienced by followers of pentecostal church Assembleia de Deus (Assembly of God) in a popular community of Rio de Janeiro. We used the qualitative method, through the use of semistructured interviews and participant observation, considering the vision of the phenomenon of individuals who are in the process. Ten participating of Assembleia de Deus (AD) were interviewed in depth, they sought this place due to problems related to drug misuse. It was observed that the search for religious treatment stems from the respect the individuals and the community have for the followers of AD, the involvement of family members of drug addicts with the church to get help to get them out of this situation, the active search the church does for them to offer them a new lifestyle and the existential crisis resulting from the loss of control over drug use and problems related to drug dealing. It has been shown that the church does the work of recovery from drug misuse in order to "cure souls" and not the treatment itself, as a means to transform society by transforming its individuals, "one by one." During therecovery process, the individual identifies with "significant others" that provide them with a structure of plausibility in order to learn a new way of interpreting the world and being in it. The individual gets away from old addicted friends or from drug dealing and begins to redefine their biography in terms of "before" and "after" the conversion. The difficulties of relationships within the church are identified as a major factor of lack ofmotivation for staying in this group. The conclusion of the study is that both thecategory person and individual are used in the recovery process. ...

Implante de stent no tronco da coronária esquerda näo protegido de paciente com choque cardiogênico / Stenting of unprotected left main coronary artery in a patient with cardiogenic shock

Mulher de 64 anos apresentou edema pulmonar e choque cardiogênico após cinecoronariografia que revelou lesão severa suboclusiva em troco de coronária esquerda (TCE) dominante. Foi submetida a angioplastia de urgência com implante de stent no TCE, com sucesso. Após evolução satisfatória, teve alta no 6º dia.