Primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care.

OBJECTIVES: To compare satisfaction with specialty care by primary care pediatricians (PCPs), perceived barriers to care, and adequacy of specialist supply. STUDY DESIGN: A survey of U.S. pediatricians was conducted in 2007. PCPs were asked about satisfaction with specialty care for their patients, as well as supply of specific pediatric subspecialists. Responses of rural and nonrural PCPs were compared regarding 10 potential barriers to care. RESULTS: Most PCPs are satisfied with the quality of subspecialty care. However, they were not satisfied with wait times for appointments, and the availability of many pediatric medical subspecialties and several pediatric surgical specialties. Rural PCPs were significantly more likely to report these shortages compared with nonrural pediatricians; these included 9 of the 18 medical and 5 of the 7 surgical specialties. In addition to wait times for appointments, PCPs reported that subspecialists' nonparticipation in health insurance plans and lack of acceptance of uninsured patients were also barriers to obtaining subspecialty care for their patients. CONCLUSIONS: PCPs provide valuable insight into access to the pediatric subspecialty workforce. This survey of PCPs raises significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities.

Teaching professionalism to residents.

The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism.

The diagnosis of intussusception.

The aims of this study were to identify features in the history, physical examination, and radiologic studies that were associated with the diagnosis of intussusception and to determine if there was a subset of patients being evaluated for intussusception who can be spared from undergoing a contrast enema based on a combination of historical, clinical, and radiographic findings. A retrospective cohort study at a regional children's hospital emergency department (ED) was conducted. Mean age was 1.2 years among both those with and without intussusception. Predictors of intussusception in the univariate analysis included history of vomiting (P=0.02), abdominal pain (P=0.1), and rectal bleeding (P=0.003); physical examination findings of abdominal mass (P<0.001), abdominal tenderness (P=0.02), and guiac positive stool (P=0.004); and plain radiograph finding of the absence of stool in the ascending colon (P<0.05). We were unable to develop a prediction model that would reliably identify all patients with the diagnosis of intussusception. Previously identified predictors of intussusception remain important in increasing suspicion of this important diagnosis. At this point there is no reliable prediction model that can accurately identify all patients with intussusception. A prospective study may aid in the development of a clinically more useful model.

Addressing core competencies through hospital quality improvement activities: attitudes and engagement.

BACKGROUND: Hospital quality improvement initiatives are becoming increasingly common. Little is known about the influence of these initiatives on resident learning and attitudes. Our objective was to assess whether training in a hospital committed to involving residents in hospital-initiated, continuous quality improvement (CQI), and to participation in such activities, would influence residents' attitudes toward CQI and engagement in the hospital community. METHODS: We surveyed Seattle Children's Hospital pediatric residents, from residency graduation years 2002-2009. We included questions about participation in quality improvement activities during residency and measures of attitude toward CQI and of workplace engagement. We used descriptive statistics to assess trends in resident participation in hospital CQI activities, attitudes toward CQI and workplace engagement. RESULTS: The overall response rate was 84% (162 of 194). Among graduated residents, there was a significant trend toward increased participation in CQI activities (P  =  .03). We found no difference in attitude toward CQI between those who had and those who had not participated in such activities nor between residents who began training before and those who began after the hospital formally committed to CQI. Sixty-three percent of residents (25 of 40) who participated in CQI activities were engaged in the hospital community compared with 53% (57 of 107) who did not participate in CQI activities (P  =  .21). CONCLUSIONS: Training in a hospital committed to involving residents in CQI was associated with a high rate of participation in CQI activities. Although such training and participation in CQI were not associated with resident attitudes toward CQI or hospital engagement, it may allow residents to learn skills for practice-based learning and improvement and systems-based practice.