Identifying Gender and Racial Bias in Pediatric Fellowship Letters of Recommendation: Do Word Choices Influence Interview Decisions?

OBJECTIVES: To describe linguistic differences in letters of recommendation (LORs) for pediatric fellowship candidates based on applicant and letter writer demographics and to examine if these differences influenced the decision to interview a candidate for a fellowship position. STUDY DESIGN: LORs for applicants to 8 pediatric subspecialty fellowships at a single academic center from the 2020 Match were analyzed in this cross-sectional study. Frequency of validated agentic and communal terms in each letter were determined by a language processing web application. Bias was determined as having a >5% surplus of agentic or communal terms. RESULTS: We analyzed 1521 LORs from 409 applicants: 69% were women, 28% were under-represented minorities in medicine (URM), and 50% were invited to interview. Overall, 66% of LORs were agentic biased, 16% communal biased, and 19% neutral. There was no difference in bias in LORs by an applicant's gender (woman 67% agentic vs man 62% agentic; P = .058), race, or ethnicity (non-URM 65% agentic vs URM 67% agentic; P = .660). Despite a lower frequency of agentic terms in LORs for applicants invited for interviews, when accounting for other components of an application and applicant demographics, no significant association was made between language bias in LORs and fellowship interview status. CONCLUSIONS: The frequency of agentic and communal terms in LORs for pediatric subspecialty fellowship candidates were not found to influence the decision to invite a candidate to interview. However, raising awareness of potential areas of bias within the pediatric fellowship selection process might lead to a more equitable and holistic approach to application review.

Feedback Culture Perceived by Trainees in an Academic Institution: A Mixed Methods Study.

OBJECTIVES: Lack of a well-functioning institutional feedback culture can undermine acquisition of skills essential for high quality patient care. The objective of this study was to assess feedback culture perceived by resident and fellow trainees, utilizing a mixed methods design. METHODS: Pediatric fellows and residents completed an anonymous feedback environment survey consisting of 7 constructs: source credibility, feedback quality, feedback delivery, reinforcing feedback, constructive feedback, source availability, and promotion of feedback seeking, using a 7-point Likert scale. Trainee ratings were compared using two-sided Fisher's exact tests. Multivariable analyses used a linear regression model. For the qualitative study, semistructured interviews of residents were conducted. The constant comparative method was used to incrementally code, categorize data, and derive themes. RESULTS: Fifty-two residents and 21 fellows completed the survey (response rates 65% and 47%, respectively). Scores were more favorable for fellows compared with residents in 6 of 7 feedback constructs (P < .05), including on multivariate analysis. Hispanic ethnicity and female gender were associated with lower scores on source credibility (P = .04) and constructive feedback (P = .03), respectively. Two qualitative themes were identified: expectation of efficiency in patient care compromises the quality and quantity of feedback, and a culture that prioritizes courtesy over candor negatively impacts feedback quality. These themes were more pronounced when residents worked with pediatric subspecialists compared with hospitalists. CONCLUSIONS: We described the feedback culture, which was less favorable in the residency program. The need for efficient patient care and a culture of courtesy adversely impacted the quality of feedback, especially among subspecialists.

Management Practices for Standard-Risk and High-Risk Patients With Bronchiolitis.

OBJECTIVE: Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions. We aim to describe and compare the management of standard-risk and high-risk patients with bronchiolitis. METHODS: This retrospective study examined patients <2 years of age admitted to the general pediatric ward with an International Classification of Diseases, 10th Revision discharge diagnosis code of bronchiolitis or viral syndrome with evidence of lower respiratory tract involvement. Patients were defined as either standard- or high-risk on the basis of previously published criteria. The frequencies of diagnostic and therapeutic interventions were compared. RESULTS: We included 265 patients in this study (122 standard-risk [46.0%], 143 high-risk [54.0%]). Increased bronchodilator use was observed in the standard-risk group (any albuterol dosing, standard-risk 65.6%, high-risk 44.1%, P = .003). Increased steroid use was observed in the standard-risk group (any steroid dosing, standard-risk 19.7%, high-risk 14.7%, P = .018). Multiple logistic regression revealed >3 doses of albuterol, hypertonic saline, and chest physiotherapy use to be associated with rapid response team activation (odds ratio [OR] >3 doses albuterol: 8.36 [95% confidence interval (CI): 1.99-35.10], P = .048; OR >3 doses hypertonic saline: 13.94 [95% CI: 4.32-44.92], P = .001); OR percussion and postural drainage: 5.06 [95% CI: 1.88-13.63], P = .017). CONCLUSIONS: A varied approach to the management of bronchiolitis in both standard-risk and high-risk children occurred institutionally. Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status. More research is needed on management strategies in patients at high-risk for severe disease.

Words Used in Letters of Recommendation for Pediatric Residency Applicants: Demographic Differences and Impact on Interviews.

OBJECTIVE: To describe differences in agentic (achievement) and communal (relationship) terms in letters of recommendation (LORs) for pediatric residency candidates by applicant and letter writer demographics and to examine if LOR language is associated with interview status. METHODS: A random sample of applicant profiles and LORs submitted to one institution were analyzed from the 2020-21 Match. Letters of recommendation text was inputted into a customized natural language processing application which determined the frequency of agentic and communal words in each LOR. Neutral LORs were defined as having< 5% surplus of agentic or communal terms. RESULTS: We analyzed 2094 LORs from 573 applicants: 78% were women, 24% were under-represented in medicine (URiM), and 39% were invited to interview. Most letter writers were women (55%) and of senior academic rank (49%). Overall, 53% of LORs were agency biased, 25% communal biased, and 23% neutral. There was no difference in agency and communally biased LORs by an applicant's gender (men 53% agentic vs women 53% agentic, P = .424), race or ethnicity (non-URiM 53% agentic vs URiM 51% agentic, P = .631). Male letter writers used significantly more agentic terms (8.5%) compared to women (6.7% agentic) or writers of both genders (3.1% communal) (P = .008). Applicants invited to interview were more likely to have a neutral LOR; however, no significant association existed between language and interview status. CONCLUSIONS: No significant differences in language were found by applicant gender or race among pediatric residency candidates. Identifying potential biases within pediatric residency selection processes is important in creating an equitable approach to application review.

Multi-gene phylogeny of North American clear-winged moths (Lepidoptera: Sesiidae): a foundation for future evolutionary study of a speciose mimicry complex.

Sesiids are a diverse group of predominantly diurnal moths, many of which are Batesian mimics of Hymenoptera. However, their diversity and relationships are poorly understood. A multi-gene phylogenetic analysis of 48 North American sesiid species confirmed the traditional taxonomic tribal ranks, demonstrated the paraphyly of Carmenta and Synanthedon with respect to several other genera and ultimately provided minimal phylogenetic resolution within and between North American and European groups. Character support from each gene suggested inconsistency between the phylogenetic signal of the CAD gene and that of the other four genes. However, removal of CAD from subsequent phylogenetic analyses did not substantially change the initial phylogenetic results or return Carmenta and Synanthedon as reciprocally monophyletic, suggesting that it was not impacting the overall phylogenetic signal. The lack of resolution using genes that are typically informative at the species level for other lepidopterans suggests a surprisingly rapid radiation of species in Carmenta/Synanthedon. This group also exhibits a wide range of mimicry strategies and hostplant usage, which could be fertile ground for future study.

Ecuadorian Coptoborus beetles harbor Fusarium and Graphium fungi previously associated with Euwallacea ambrosia beetles.

Ambrosia beetles from the scolytine tribe Xyleborini (Curculionidae) are important to the decomposition of woody plant material on every continent except Antarctica. These insects farm fungi on the walls of tunnels they build inside recently dead trees and rely on the fungi for nutrition during all stages of their lives. Such ambrosia fungi rely on the beetles to provide appropriate substrates and environmental conditions for growth. A small minority of xyleborine ambrosia beetle-fungal partnerships cause significant damage to healthy trees. The xyleborine beetle Coptoborus ochromactonus vectors a Fusarium (Hypocreales) fungus that is lethal to balsa (Ochroma pyramidale (Malvaceae)) trees in Ecuador. Although this pathogenic fungus and its associated beetle are not known to be established in the United States, several other non-native ambrosia beetle species are vectors of destructive plant diseases in this country. This fact and the acceleration of trade between South America and the United States demonstrate the importance of understanding fungal plant pathogens before they escape their native ranges. Here we identify the fungi accompanying Coptoborus ambrosia beetles collected in Ecuador. Classification based ribosomal internal transcribed spacer 1 (ITS) sequences revealed the most prevalent fungi associated with Coptoborus are Fusarium sp. and Graphium sp. (Microascales: Microascaceae), which have been confirmed as ambrosia fungi for xyleborine ambrosia beetles, and Clonostsachys sp. (Hypocreales), which is a diverse genus found abundantly in soils and associated with plants. Phylogenetic analyses of the Fusarium strains based on ITS, translation elongation factor (EF1-α), and two subunits of the DNA-directed RNA polymerase II (RPB1 and RPB2) identified them as Fusarium sp. AF-9 in the Ambrosia Fusarium Clade (AFC). This Fusarium species was previously associated with a few xyleborine ambrosia beetles, most notably the species complex Euwallacea fornicatus (Eichhoff 1868) (Curculionidae: Scolytinae: Xyleborini). Examination of ITS and EF1-α sequences showed a close affinity between the Graphium isolated from Coptoborus spp. and other xyleborine-associated Graphium as well as the soil fungus Graphium basitruncatum. This characterization of ambrosia fungi through DNA sequencing confirms the identity of a putative plant pathogen spread by Coptoborus beetles and expands the documented range of Fusarium and Graphium ambrosia fungi.

The Effect of Sitting Versus Standing on Family Perceptions of Family-Centered Rounds.

OBJECTIVE: Previous studies reveal improved perception of time spent, as well as overall experience, for patients when their inpatient provider is seated during an encounter. With our study, we aim to establish whether family experience and perception of time is improved when a pediatric inpatient provider team sits for patient and family-centered rounds. PATIENTS AND METHODS: From February 2017 to November 2017, 99 inpatient encounters were randomly assigned to either a sitting or standing rounding team. Mean total time spent on rounds, family perception of time spent on rounds, and overall family experience with rounds (by using top-box analysis of physician communication questions) were compared between the 2 groups. RESULTS: Total time spent on rounds was similar between the 2 groups (14.2 minutes in the sitting group and 12.7 minutes in the standing group; P = .23), and families in general overestimated the time spent with physicians in both groups (15.9 minutes in sitting group and 14.8 minutes in the standing group; P = .45). There were no significant differences in top-box experience responses (62% in sitting and 55% in standing; P = .12). CONCLUSIONS: Sitting during the patient and family-centered rounds encounter did not affect actual or perceived time spent during rounds. Families may have a slightly more positive experience with seated rounds, but the difference in this study did not reach a level of statistical significance.

Patient- and Family-centered Rounding: A Single-site Look into the Room.

INTRODUCTION: The American Academy of Pediatrics recommends Patient- and Family-centered Rounds (PFCRs) to improve communication between the healthcare team and families while allowing the latter to participate in medical decision-making. PFCRs have a secondary goal of increasing rounds' efficiency and providing a positive learning environment for residents and students. There are many published best practices for PFCR. Our study provides an observational evaluation of PFCR in an academic tertiary medical center using a checklist created from such published best practices. METHODS: We created a standardized observation checklist based on published guidelines. Study members observed 200 individual rounding encounters using this instrument. All inpatient, nonsurgical rounding teams in the fall of 2014 were included and analyzed using descriptive statistics. RESULTS: The average rounding encounter included 9 team members, lasted 9 minutes and 24 seconds, with the medical team entering the patient room for 80.0% of encounters. Families were invited to participate in 60% of the encounters. Lay language was utilized in 62% of the encounters, although 99.5% of the encounters staff used medical terminology. Nursing was present in 64.5% of encounters but presented in only 13.5% of those encounters. The teaching-attending modeled patient interaction behaviors such as eye contact, nodding, and leaning forward in 31%-51% of encounters. CONCLUSIONS: Despite published best practices, medical teams at a large tertiary care center did not adhere to many components of published PCFR guidelines. Future studies should focus on family and physician experience to identify improvement strategies for rounds.

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome.

OBJECTIVES: This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN: We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS: The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS: Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Firearms Screening in the Pediatric Inpatient Setting.

OBJECTIVES: Firearm-related deaths remain a top cause of mortality in American children and adolescents. In a 2012 policy statement, the American Academy of Pediatrics urged pediatricians to incorporate questions about the availability of firearms into their patient history taking. We aim to evaluate the frequency of screening for home firearms in an academic tertiary-care hospital inpatient setting. METHODS: This retrospective chart review examined patients with the following pediatric diagnoses admitted to a tertiary-care pediatric hospital from 2006 to 2015: asthma, bronchiolitis, cellulitis, jaundice, single liveborn infant, bacterial and viral pneumonia, and all mood disorders. Data analysts then searched the patient charts that met these inclusion criteria for documentation of firearm screening as indicated by use of the terms "firearm," "pistol," "gun," "handgun," "bullet," "ammunition," or "rifle" in the admissions history and physical. RESULTS: Evidence of screening for firearms in the home was found in 1196 of the 40 658 charts included in the study (2.94%). The most frequently screened diagnosis and admitting service were mood disorders and child psychiatry, respectively (1159 of 3107; 37.3%). Only 19.8% of identified gun-owning families received specific anticipatory guidance. CONCLUSIONS: Firearm screening and gun safety education occurred infrequently in the inpatient setting. Inpatient encounters may provide an opportunity for increased screening and education because the hospital environment also includes additional resources, exposure to a greater number of providers, and the presence of more family members or caregivers. Further studies are warranted to explore barriers to inpatient screening and possible mechanisms for improvement.

X + Y Scheduling in Pediatric Residency: Continuity, Handoffs, and Trainee Experience.

BACKGROUND: Many internal medicine residency programs have transitioned to an X + Y clinic schedule, in which weekly continuity clinics are removed and clinic experience is instead condensed into 2-week blocks interspersed throughout the year, but few pediatric training programs have adopted this approach. We initiated X + Y scheduling in the 2015 academic year, with the hypothesis that outpatient continuity could be maintained or improved while inpatient handoffs would be reduced. We also hypothesized that learner experience with X + Y scheduling would be positive. METHODS: Continuity and handoffs were compared over a 7-month period in 2013 to 2014 and 2015 to 2016. Outpatient continuity was calculated as the proportion of visits in which the patient was seen by the designated primary care provider (PCP). Handoffs were calculated through analysis of the online resident schedule with comparison of weekly totals for all inpatient teams. Resident perceptions were obtained in an online survey of residents who experienced both systems. RESULTS: With X + Y scheduling, overall outpatient continuity improved from 2914 of 9882 (29.5%) of visits seen by a patient's PCP to 3066 of 9769 (31.4%) (P = .004), but preventive visit continuity decreased from 2170 of 4687 (46.2%) to 2025 of 4709 (43%) (P = .001). Inpatient handoffs decreased with X + Y scheduling from 30 to 20 weekly handoffs (P < .001). In total, 85% of residents reported a positive experience with X + Y scheduling. CONCLUSIONS: An X + Y scheduling approach in pediatrics is a viable alternative to weekly clinics, resulting in improved learner experience, reductions in inpatient handoffs, and small mixed effects on outpatient continuity.

Pediatric Chief Residents' Experiences as Inpatient Attending Physicians.

BACKGROUND: Some pediatric chief residents perform supervisory clinical duties during chief residency, but these activities are highly variable and descriptions are limited. Our goals were to characterize inpatient service performed by pediatric chief residents and to explore factors that influence their experiences as inpatient attending physicians. METHODS: Pediatric chief residents at Accreditation Council for Graduate Medical Education-accredited programs in 2016 were invited to complete a 40-item electronic questionnaire about their inpatient service obligation as well as attitudes regarding this experience. Data were analyzed using Chi-square, analysis of variance tests, and logistic regression. Open-ended responses underwent content analysis. RESULTS: There were 116 completed surveys from a national sample of 223 (response rate 52%); 66% served as inpatient attending physicians during chief residency. On average, chief residents spent 5.5 weeks (range 1-16) in this role with a daily census of 11.5 patients (range 5-20). Those entering primary care were significantly less likely to spend time as an inpatient attending compared with chiefs entering fellowship or hospital medicine (45.7 vs 67.3 vs 83.3%, P = .01). Overall, 92% regarded their inpatient clinical experience positively and indicated they would like the same (40%) or more time (52%) in this role. The average favorability rating was 8.2 of 10, and this was not associated with clinical workload or career choice. CONCLUSIONS: Most chief residents serve as inpatient attending physicians during chief residency. They rate their inpatient experience positively despite wide variability in clinical experiences, patient population, and clinical load. Further studies should examine the value of this experience and its impact on chief residents' future practice.

Adherence to AAP Healthy Newborn Discharge Criteria in a Tertiary Care Children's Hospital.

OBJECTIVES: In 2015, the American Academy of Pediatrics (AAP) published an updated consensus statement containing 17 discharge recommendations for healthy term newborn infants. In this study, we identify whether the AAP criteria were met before discharge at a tertiary care academic children's hospital. METHODS: A stratified random sample of charts from newborns who were discharged between June 1, 2015, and May 31, 2016, was reviewed. Of the 531 charts reviewed, 433 were included in the study. A review of each chart was performed, and data were collected. RESULTS: Descriptive statistics for our study population (N = 433) revealed that all 17 criteria were followed <5% of the time. The following criteria were met 100% of the time: clinical course and physical examination, postcircumcision bleeding, availability of family members or health care providers to address follow-up concerns, anticipatory guidance, first appointment with the physician scheduled or parents knowing how to do so, pulse oximetry screening, and hearing screening. These criteria were met at least 95% to 99% of the time: appropriate vital signs, regular void and stool frequency, appropriate jaundice and sepsis management, and metabolic screening. The following criteria were met 50% to 95% of the time: maternal serologies, hepatitis B vaccination, and social risk factor assessment. Four of the criteria were met <50% of the time: feeding assessment, maternal vaccination, follow-up timing for newborns discharged at <48 hours of life, and car safety-seat assessment. CONCLUSIONS: Our data reveal that the AAP healthy term newborn discharge recommendations are not consistently followed in our institution.

A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.