A Pilot Survey on the Perceptions of Pediatric Subspecialty Fellows and Program Directors on Virtual Compared with In-Person Interview Experiences.

Pediatric fellowship programs have conducted virtual interviews since the start of the COVID-19 pandemic in 2020. In this national survey of fellowship program directors and fellows interviewed in-person and virtually, fellowship program directors and fellows formed accurate impressions, regardless of format, but our data did not clearly support one interview format over another.

WITHDRAWN: Update in Asthma 2021.

Ahead of Print article withdrawn by publisher.

Peer evaluations in an anonymous and open system: Intern reactions and evaluation analysis.

PURPOSE: Feedback and evaluation from peers is fundamental to trainees' professional development but may be uncomfortable to provide non-anonymously. We aimed to understand resident perception of anonymous and open written evaluation systems and to analyze evaluations in each of these systems. MATERIALS AND METHOD: We compared two years of intern peer evaluations at a large United States-based pediatric residency program - the 2018-2019 and 2019-2020 years during which intern peer evaluations were anonymous and open, respectively. We electronically surveyed interns about their perceptions of peer evaluations and analyzed four aspects of the evaluations themselves: (1) orientation, (2) caliber, (3) Likert-scale, and (4) word count. RESULTS: 40 (78%) and 38 (75%) interns participated in the survey in the anonymous and open years, respectively. Respondents reported being more likely to avoid writing constructive comments in the open year. There were more high caliber comments in the open year. Likert-scale ratings of peers were lower in the open year. Word count was longer in the open year. CONCLUSIONS: While interns expressed more discomfort evaluating peers in an open evaluation system, they wrote longer and more high caliber comments in an open system than in an anonymous system. Residency programs should consider professional development in writing peer evaluation.

Residents are uncomfortable writing constructive comments in peer evaluations, particularly in open formats.Residents write similar numbers of constructive comments whether the evaluation is delivered anonymously or in an open format.Residents write more high caliber comments when evaluations are delivered in an open format than when delivered anonymously.Residents write longer comments when evaluations are in an open format.Program leaders should weigh the increased number of high caliber peer evaluations in an open system with resident preference for an anonymous system when designing their peer evaluation systems.

Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation.

BACKGROUND: "Bridging" is a term used to describe the implementation of various treatment modalities to improve waitlist survival while a patient awaits lung transplantation. ECMO and PLAD are technologies used to bridge patients to lung transplantation. ECMO and PLAD are cardiopulmonary support systems that help move blood forward while using an artificial membrane to remove CO2 from and add O2 to the blood. Recent studies showed that these technologies are increasingly effective in bridging patients to lung transplantation, especially with optimizing patient selection, implementing physical rehabilitation and ambulation goals, standardization of management decisions, and increasing staff experience, among other considerations. We review these technologies, their roles as bridges to pediatric lung transplantation, as well as indications, contraindications, complications, and mortality rates. CONCLUSION: Finally, we discuss the existing knowledge gaps and areas for future research to improve patient outcomes and understanding of lung assist devices.

A review of toxic effects of electronic cigarettes/vaping in adolescents and young adults.

In this review, we examine the known and suspected toxicity of electronic cigarettes (e-cigarettes) in adolescents and young adults, to improve awareness of risks and identification of complications of their use. The use of e-cigarettes, or "vaping," is exploding among the pediatric population. E-cigarettes heat a solution containing a psychoactive compound, most commonly nicotine or tetrahydrocannabinol (THC), along with flavorings and other additives to a vapor, which users inhale. Since their introduction in the early 2000s, e-cigarette use is now prolific among youth, per the Monitoring the Future survey, with over 40% of high school seniors reporting use within the past year. Adolescents are vulnerable to the risks of e-cigarettes, as they are targeted as new consumers with advertisements and flavoring compounds, and are not utilizing them as a means to smoking cessation. The pulmonary risks of vaping are rapidly emerging, with the most immediately alarming being the condition electronic-cigarette/vaping associated lung injury (EVALI). Additionally, there have been more recent studies showing extrapulmonary effects including cardiovascular, immunologic and neuro-developmental effects. Many of these effects are likely dose-dependent. Public health efforts are urgently needed to decrease or eliminate new e-cigarette initiation, and support should be established to assist current e-cigarette users with cessation. We strongly advocate for the elimination of e-cigarette flavorings and advertising directed at adolescents, and call for physicians to be cognizant of this expanding epidemic.

Pediatric Hemoptysis without Bronchiectasis or Cardiac Disease: Etiology, Recurrence, and Mortality.

OBJECTIVES: To describe the etiologies of hemoptysis in patients without pre-existing bronchiectasis or cardiac disease; to assess odds of recurrent hemoptysis by diagnostic category; and to assess odds of mortality by diagnostic category. STUDY DESIGN: This retrospective case series included all patients with hemoptysis documented during an admission to Boston Children's Hospital from January 1, 2007 to June 1, 2017. Patients with bronchiectasis, congenital heart disease, primary pulmonary hypertension, bleeding above the glottis, hemoptysis before 38 weeks of corrected gestational age, hematemesis, foreign body, and trauma were excluded. Patients were also characterized by coagulation status. Primary outcomes were recurrent hemoptysis and death. Univariate analysis was performed to determine ORs for recurrence and death per diagnostic category with infection as the reference category. RESULTS: In total, 257 patients met study criteria and were analyzed. The most common causes of hemoptysis were infection (n = 122), neoplasm (n = 58), and other diagnoses (n = 49). Of the patients with infection, recurrence was 28% and all-cause mortality was 12%. Neoplasm had lower odds of recurrence (OR 0.3, P = .012) but higher odds of mortality (OR 15.8, P < .001). Thrombocytopenia had lower odds of recurrence (OR 0.2, P = .005) but higher odds of mortality (OR 5.9, P < .001). Patients with a tracheostomy had higher odds of recurrence (OR 6.3, P < .001), but lower odds of death (OR 0.4, P = .042). CONCLUSIONS: This study confirms that infection is the most common cause of hemoptysis in patients without severe underlying pulmonary or cardiac disease. Hemoptysis associated with neoplasm and/or thrombocytopenia confers mortality risk. Tracheostomy confers risk of recurrence. Future prospective research on diagnoses associated with hemoptysis is warranted.

Virtual interviews and equity: The pediatric pulmonary fellow perspective.

BACKGROUND AND OBJECTIVES: The SARS-CoV-2 pandemic shifted medical training programs to utilize virtual interviews (VIs) starting with the 2020 interview cycle. Fellowship interviews continue in the virtual format. It is unknown how this shift has affected equity for applicants as compared to in-person interviews. Equity in this study includes consideration of the opportunity for an applicant to accept, access, and conduct a VI. This study assessed pediatric pulmonary fellows' perception of equity associated with VIs and preferences for future cycles. METHODS: An anonymous survey link was emailed to Pediatric Pulmonology Program Directors to disseminate to incoming and first-year pediatric pulmonary fellows who participated in the 2022-2023 and 2021-2022 VI seasons. Responses were summarized by frequency and percentages. Inductive coding was used to thematically analyze free-text responses. RESULTS: Nearly 30% of eligible incoming and first-year pulmonary fellows (n = 35/119, 29.4%) completed the survey. Seventy-four percent felt that VIs reduce inequities as compared to in-person interviews. Sixty percent felt that VIs were the most equitable format, and 51% chose a VI as their preferred future format. Important practice considerations to promote equity for future VIs included providing applicants with instruction for the expected dress code, followed by providing applicants with virtual technology (91% and 89% of respondents ranked as at least "somewhat important," respectively). CONCLUSION: VIs were perceived as a more equitable interview format by pediatric pulmonology fellows compared to in-person interviews in our study. To increase equity for VIs, program directors can consider additional adaptations such as providing standardized instruction for dress code and providing the required technology.

Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

Expectations versus reality: Understanding the accuracy of impressions made during virtual interviews of pediatric pulmonary fellowship programs.

RATIONALE: As a result of the SARS-CoV-2 pandemic, all pediatric pulmonary fellowship programs conducted virtual interviews for the first time in the Fall of 2020. This study aimed to understand the accuracy of virtual-interview derived-impressions of fellowship programs, as well as applicant preference for future fellowship interview cycles. METHODS: A group of pediatric pulmonary fellows and Program Directors designed a REDCap survey. The survey was distributed to all first-year pediatric pulmonary fellows who participated in the 2020-2021 virtual interview season. RESULTS: 23/52 (44%) of first-year pediatric pulmonary fellows completed the survey. 96% were able to form general impressions about fellowship programs during their virtual interviews. 96% reported that generally their fellowship experience matched their virtual-interview derived-impressions. 17 of the 19 factors applicants use to rank programs had no statistically significant change (p > 0.05) in impression from virtual interview to fellowship experience. The two factors with a statistically significant (p < 0.05) change in impression were patient care related-volume of "bread and butter" pediatric pulmonary patients and volume of tertiary care pediatric pulmonary patients. 87% prefer some form of in-person interview option in future application cycles. A tiered interview format in which applicants are first invited to a virtual interview day followed by an optional in-person second look day was the most popular preference for future interview cycles (48%). CONCLUSIONS: Virtual interviews may provide accurate representations of pediatric pulmonary fellowship programs and applicants prefer some type of in-person interview option in future application cycles.

Changes Made to Orders Placed by Overnight Admitting Residents on Teaching Rounds the Next Day.

OBJECTIVES: Increased focus on health care quality and safety has generally led to additional resident supervision by attending physicians. At our children's hospital, residents place orders overnight that are not explicitly reviewed by attending physicians until morning rounds. We aimed to categorize the types of orders that are added or discontinued on morning rounds the morning after admission to a resident team and to understand the rationale for these order additions and discontinuations. METHODS: We used our hospital's data warehouse to generate a report of orders placed by residents overnight that were discontinued the next morning and orders that were added on rounds the morning after admission to a resident team from July 1, 2017 to June 29, 2018. Retrospective chart review was performed on included orders to determine the reason for order changes. RESULTS: Our report identified 5927 orders; 538 were included for analysis after exclusion of duplicate orders, administrative orders, and orders for patients admitted to non-Pediatric Hospital Medicine services. The reason for order discontinuation or addition was medical decision-making (n = 357, 66.4%), change in patient trajectory (n = 151, 28.1%), and medical error (n = 30, 5.6%). Medical errors were most commonly related to medications (n = 24, 80%) and errors of omission (n = 19, 63%). CONCLUSIONS: New or discontinued orders commonly resulted from evolving patient management decisions or changes in patient trajectory; medical errors represented a small subset of identified orders. Medical errors were often errors of omission, suggesting an area to direct future safety initiatives.

A Unique Lens: Understanding What Nurses Are Best Positioned to Assess About Residents.

Background: Resident feedback is generally elicited from attending physicians, although nurses can also provide feedback on distinct domains. Physicians may be hesitant to accept feedback from nurses if they perceive that nurses are being asked about areas outside their expertise. Understanding specific resident behaviors that nurses are best suited to assess is critical to successful implementation of feedback from nurses to residents. Objective: To understand specific resident behaviors nurses are uniquely positioned to assess from the perspectives of both nurses and residents. Methods: We performed a qualitative study using thematic analysis of 5 focus groups with 20 residents and 5 focus groups with 17 nurses at a large free-standing children's hospital in 2020. Two reviewers developed a codebook and subsequently analyzed all transcripts. Codes were organized into themes and subthemes. Thematic saturation was achieved prior to analyzing the final transcript. Results: We identified 4 major themes. Nurses are positioned to provide feedback: (1) on residents' interprofessional collaborative practice; (2) on residents' communication with patients and their families; and (3) on behalf of patients and their families. Within each of these, we identified subthemes noting specific behaviors on which nurses can provide feedback. The fourth theme encompassed topics that may not be best suited for nursing feedback-medical decision-making and resident responsiveness. Conclusions: Nurses and residents described specific resident behaviors that nurses were best positioned to assess.

Pediatric EVALI in the Age of COVID-19/MIS-C: Diagnostic Considerations.

OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) and e-cigarette or vaping product use-associated lung injury (EVALI) have significant overlap in clinical features, which can contribute to delay in identification and treatment. The objectives of this report were to identify and describe features that are common in both diagnoses and those that may help distinguish EVALI from MIS-C, and to highlight the diagnostic challenges observed at our tertiary medical center. METHODS: We identified adolescents diagnosed with MIS-C who had respiratory or gastrointestinal symptoms and patients diagnosed with EVALI during the same time period. We compared demographics, history, clinical manifestations, laboratory findings, and features of the hospital course to determine areas of overlap between MIS-C and EVALI, as well as distinct features of each diagnosis. Mann-Whitney U test was used to compare continuous variables and Fisher's exact test was used to compare categorical variables. RESULTS: We found that cardiovascular and mucocutaneous findings and thrombocytopenia were more common in MIS-C. EVALI patients had a higher degree of inflammation and history of antecedent weight loss. Providers at our institution were more likely to consider MIS-C than EVALI on the differential diagnosis, including in patients with vaping history and no evidence of previous severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: This study emphasizes the need for a thorough collection of substance use history for all patients and consideration of EVALI in adolescents who present with respiratory compromise or gastrointestinal symptoms and systemic inflammation, particularly in the absence of severe acute respiratory syndrome coronavirus 2 exposure or cardiac findings characteristic of MIS-C.

Bridge Builders: A Qualitative Study of Fellows' Successful Supervision of Residents.

PURPOSE: Clinical fellows, those training to become subspecialists in a program certified by the Accreditation Council for Graduate Medical Education, supervise residents on inpatient subspecialty rotations. Unlike for supervising residents or for faculty, there is a paucity of literature describing fellows' supervision of residents. The aim of this study was to understand residents' and fellows' perception of successful supervision of residents by fellows on inpatient subspecialty rotations to inform the development of curricula to support fellows as supervisors. METHOD: Using grounded theory methodology, the authors held focus groups in May 2020 of pediatric residents and pediatric subspecialty fellows at Boston Children's Hospital, Boston, Massachusetts. Focus groups were conducted until thematic saturation was achieved. Deidentified transcripts were independently coded by 2 authors. The author team consolidated the codes into themes and developed an interpretive model for fellows' successful supervision of residents. Key results were confirmed via member checking. RESULTS: The authors conducted 4 resident focus groups, composed of 16 pediatric residents, and 4 fellow focus groups, composed of 13 pediatric subspecialty fellows. Participants perceived that fellows who provided successful resident supervision advanced residents' professional growth and supported residents' development along 5 "bridges": (1) generalist to subspecialist, (2) trainee to autonomous practitioner, (3) individual to member of the interprofessional team, (4) emerging physician to patient-facing care provider, and (5) newcomer to engaged clinical learner. Fellows can further residents' growth in these areas by demonstrating approachability, empathy, appreciation, and kindness. CONCLUSIONS: As newcomers on inpatient subspecialty rotations, residents engage in legitimate peripheral participation. Fellows who are successful supervisors move residents toward full participation in their profession via the bridge model. The fellow-resident dynamic carries advantages of near-peer learning. Fellows can harness their role, subspecialty knowledge, and familiarity with the training environment to enhance resident supervision.

Case series: Adolescent victims of the vaping public health crisis with pulmonary complications.

Alongside the epidemic use of electronic cigarettes (e-cigarettes) across the country, evidence of multiple pulmonary complications has emerged, with the most immediately life-threatening being the new clinical condition of e-cigarette/vaping-associated lung injury (EVALI), with investigation actively underway to further define this entity and determine the cause or causes. We present a series of cases of respiratory illnesses associated with e-cigarette use, many of which meet criteria for suspected or confirmed EVALI, managed at a pediatric tertiary care center, demonstrating notable variation in presenting symptoms and severity. Most cases improved with supportive respiratory care and the administration of corticosteroids and antibiotics, although generally no infection was found. The cases also tend to show improvement with discontinuation of the use of e-cigarettes. We discuss challenges in determining the contribution of e-cigarettes to the case pathology and review possible diagnostic and treatment options. In patients suffering from e-cigarette-related respiratory illness including EVALI, the primary treatment goal should be the cessation of e-cigarette use and avoidance of other possible pulmonary toxins, including conventional cigarettes. Prevention of e-cigarette use is critical in the youth population, as these patients are typically nicotine naïve and do not engage in smoking conventional cigarettes before initiation of vaping.

Defining the Essential Components of a Teaching Service.

OBJECTIVES: A large portion of residency education occurs in inpatient teaching services without widely accepted consensus regarding the essential components that constitute a teaching service. We sought to generate consensus around this topic, with the goal of developing criteria programs that can be used when creating, redesigning, or evaluating teaching services. METHODS: A list of potential components of teaching services was developed from a literature search, interviews, and focus groups. Eighteen pediatric medical education experts participated in a modified Delphi method, responding to a series of surveys rating the importance of the proposed components. Each iterative survey was amended on the basis of the results of the previous survey. A final survey evaluating the (1) effort and (2) impact of implementing components that had reached consensus as recommended was distributed. RESULTS: Each survey had 100% panelist response. Five survey rounds were conducted. Fourteen attending physician characteristics and 7 system characteristics reached consensus as essential components of a teaching service. An additional 25 items reached consensus as recommended. When evaluating the effort and impact of these items, the implementation of attending characteristics was perceived as requiring less effort than system characteristics but as having similar impact. CONCLUSIONS: Consensus on the essential and recommended components of a resident teaching service was achieved by using the modified Delphi method. Although the items that reached consensus as essential are similar to those proposed by the Accreditation Council for Graduate Medical Education, those that reached consensus as recommended are less commonly discussed and should be strongly considered by institutions.

Applying Cognitive Learning Strategies to Enhance Learning and Retention in Clinical Teaching Settings.

Introduction: Cognitive learning strategies are strategies that improve a learner's ability to process information more deeply, transfer and apply information to new situations, and result in enhanced and better-retained learning. Methods: We developed an interactive workshop for a national conference of pediatric educators to teach five cognitive learning strategies. The specific strategies were (1) spaced retrieval practice, (2) interleaving, (3) elaboration, (4) generation, and (5) reflection. Each strategy was taught using an active learning exercise. We evaluated the effectiveness of the workshop through a commitment-to-change exercise in which we asked participants to commit to making a change in their teaching as it related to the workshop and then queried them 6 weeks later about their implementation successes and barriers. Results: Of the 161 participants registered for the workshop, 52 completed the voluntary workshop evaluation. All 52 participants committed to making a change in their teaching as a result of the workshop. Of those 52 participants, 24 completed the 6-week follow-up survey. Eighty-two percent of those respondents (n = 18) reported implementing a change based on the workshop, with 77% of respondents implementing a change that they had committed to directly after the workshop and 55% implementing a change that they had not originally committed to at the end of the workshop. Discussion: This workshop successfully led to behavioral change in the teaching of cognitive learning strategies. We anticipate that this will lead to improved learning among the trainees whom participants teach.