The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study.

BACKGROUND AND OBJECTIVES: With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams. METHODS: In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis. RESULTS: Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows. CONCLUSIONS: This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States.

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Understanding burnout in Pediatric residency through the lens of the 'Areas of worklife'.

BACKGROUND AND OBJECTIVES: Burnout is a widespread problem in medicine, especially among trainees. Despite this, data on effective interventions are limited. An organizational context for burnout entitled Areas of Worklife identified six areas of the work environment that can affect burnout through mismatches between individuals expectations of that area and the reality of the work environment. This study aimed to gain a deeper understanding of pediatric residents' perspectives of the Areas of Worklife to allow programs to utilize this framework in the development of future interventions. METHODS: Using qualitative methodology founded in grounded theory, we employed an iterative data collection by conducting semi-structured interviews, until data saturation was achieved, with 15 pediatric residents in 2018. We recorded interviews and transcribed them verbatim. Content analysis was conducted concurrently with data collection using constant comparison methods; the principal investigator and co-investigators worked jointly to generate codes and identify themes. RESULTS: Themes were identified for the individual Areas of Worklife that represented resident perspectives and mismatches with the work environment. Overall, patient care was a central focus connecting the areas of control, reward, values, and workload; themes in these areas concentrated on resident's ability to interact with and learn from patients. CONCLUSIONS: Residents' definitions of the Areas of Worklife can be used to identify mismatches between residents' expectations and their work environment, which can inform organizational interventions. These findings highlight the importance of a patient-focused approach to residency training, which is consistent with literature that shows patient care is a means to find meaning in their work. Resident definitions of the Areas of Worklife offer residency programs a practical approach in their battle against burnout by providing focused direction to respond to resident needs and identify tangible targets for intervention.

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.

OBJECTIVES: Idiosyncratic approaches to reasoning among teachers and limited reliable workplace-based assessment and feedback methods make teaching diagnostic reasoning challenging. The Assessment of Reasoning Tool (ART) was developed to fill this gap, but its utility and feasibility in providing feedback to residents has not been studied. We evaluated how the ART was used to assess, teach, and guide feedback on diagnostic reasoning to pediatric interns. METHODS: We used an integrated mixed-methods approach to evaluate how the ART facilitates the feedback process between clinical teachers and learners. We collected data from surveys of pediatric interns and interviews of hospital medicine faculty at Baylor College of Medicine from 2019 to 2020. Interns completed the survey each time they received feedback from their attending that was guided by the ART. The preliminary intern survey results informed the faculty interview questions. We integrated descriptive statistics of the survey with the thematic analysis of the transcribed interviews. RESULTS: Survey data (52 survey responses from 38 interns) and transcribed interviews (10 faculty) were analyzed. The ART framework provided a shared mental model which facilitated a feedback conversation. The ART-guided feedback was highly rated in terms of structure, content, and clarity in goal-setting while enabling new learning opportunities. Barriers to using the ART included limited time and inter-faculty variability of its use. CONCLUSIONS: The ART facilitated effective and feasible faculty feedback to interns on their diagnostic reasoning skills.

How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study.

OBJECTIVE: To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents. METHODS: We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains. RESULTS: We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief. CONCLUSIONS: We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.

Chronic Ulcers and Malnutrition in an African Patient.

An 11-year-old girl with a congenitally malformed left hand, sickle cell trait, asthma, and history of appendicitis was transferred from Zambia for evaluation and treatment of widespread suppurative and ulcerative skin lesions that typically appeared after trauma to her skin. The ulcers first presented 3 years earlier but had markedly worsened in the 9 months before transfer, spreading circumferentially on her extremities and abdomen at the site of an appendectomy. They were painful and did not resolve with multiple courses of intravenous antibiotics and close management by a pediatric infectious disease specialist working for a nongovernmental organization (NGO) in her home country. Per NGO records, she had previously been  average weight-for-age. On presentation after international transfer, she was severely malnourished, with lesions covering âˆ¼35% of her body. In initial workup, leukocytosis of 21 × 103 cells per µL (79% neutrophils), hemoglobin of 6.1 g/dL, and mean corpuscular volume of 66 fL were found. Iron studies revealed an iron level of 18 µg/dL, ferritin level of 55 ng/mL, total iron binding capacity of 222 µg/dL, and transferrin saturation of 8%. Inflammatory markers were elevated, C-reactive protein was 20.1 mg/dL, and the erythrocyte sedimentation rate was 131 mm/h. A chest computed tomography scan revealed bilateral pulmonary nodules, the largest in her left upper lobe measuring 2.4 × 2.0 × 1.9 cm. Our panel of experts reviews the evaluation and treatment of this patient with extensive suppurative and ulcerative skin lesions and the factors considered in offering charity care to international patients.

Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout.

OBJECTIVE: Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout. METHODS: Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory. RESULTS: Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9-7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7-23.5) than hospitalists. The most frequent source of moral distress was "having excessive documentation requirements that compromise patient care," and the most intense source of moral distress was "be[ing] required to work with abusive patients/family members who are compromising quality of care." Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5-41.2). CONCLUSIONS: Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.

Caregivers' Perceptions and Hospital Experience After a Brief Resolved Unexplained Event: A Qualitative Study.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published guidelines for evaluation and management of lower-risk infants for a brief resolved unexplained event (BRUE). The guideline identified gaps in knowledge related to caregiver satisfaction, anxiety, and family-centered educational strategies to improve caregiver experience and patient outcomes. The objective of this study was to understand caregivers' experience with hospitalization for infants with BRUE, including their perception of the hospital stay, the diagnosis of BRUE, and their feelings toward the upcoming discharge from the hospital. METHODS: We conducted a qualitative study using semistructured interviews with caregivers of infants aged 0 to 12 months who were admitted to a quaternary care children's hospital for a BRUE. Interviews were conducted within 24 hours of discharge. Two investigators coded transcripts and identified themes using consensus. RESULTS: Eighteen caregivers of 13 infants were interviewed. No infants met criteria for being low risk according to the American Academy of Pediatrics guidelines. The coding scheme produced 3 major themes. First, parents felt reassured by hospital monitoring, diagnostic evaluation, and staff support in the hospital. Second, parents felt unsettled by the uncertainty of the child's condition and whether BRUE's "unexplainable" quality is understood as being part of normal infant behavior. Third, these themes manifested as conflicting emotions about caregivers' readiness for discharge. CONCLUSIONS: Although hospital monitoring may provide reassurance for some caregivers, they continue to struggle with the uncertainty of the diagnosis. Caregiver perspectives can inform physicians' strategies to improve hospital experience and discharge readiness.

Using Appreciative Inquiry to Inform Program Evaluation in Graduate Medical Education.

BACKGROUND: Graduate medical education programs are expected to conduct an annual program evaluation. While general guidelines exist, innovative and feasible approaches to program evaluations may help efforts at program improvement. Appreciative Inquiry is an approach that focuses on successful moments, effective processes, and programs' strengths. OBJECTIVE: We implemented a novel application of Appreciative Inquiry and its 4 phases (Inquire, Imagine, Innovate, and Implement) and demonstrate how it led to meaningful improvements in a pediatric pulmonology fellowship program. METHODS: As part of the Inquire and Imagine phases, the authors developed an interview guide that aligned with Appreciative Inquiry concepts. Two faculty members conducted semistructured interviews with a convenience sample of 11 of 14 fellowship alumni. Interviews were audiotaped, transcribed, and reviewed. A summary of the findings was presented to the Program Evaluation Committee, which then directed the Innovate and Implement phases. RESULTS: Appreciative Inquiry was acceptable to the alumni and feasible with the authors' self-directed learning approach and minimal administrative and financial support. In the Inquire phase, alumni identified program strengths and successes. In the Imagine phase, alumni identified program changes that could aid transition to independent practice for future fellows (an identified program goal). Based on the results of the Appreciative Inquiry, program leadership and the Program Evaluation Committee selected improvements for implementation. CONCLUSIONS: For small programs, Appreciative Inquiry is an innovative and feasible approach to program evaluation that facilitates actionable program improvement recommendations.

Teamwork on Rounds on an Inpatient Ward Team: An Ethnographic Study.

BACKGROUND AND OBJECTIVES: Pediatric hospitalists are expected to be adept at effective teamwork; yet, studies in which researchers describe teamwork practices in general pediatric inpatient settings are lacking. Our aim in this study was to examine the roles that general pediatric team members assume in real-life settings and how team members conduct teamwork practices on family-centered rounds. METHODS: In the ethnographic tradition, we observed a general pediatric team on a hospitalist service, focusing on family-centered rounds, and conducted in-depth interviews with interns, senior residents, and faculty. We collected data in the form of field notes from observations and transcribed interviews and used constant comparison methods to create codes and generate themes. We used Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as an analytic lens and organizing framework. RESULTS: Communication occurred in both structured and unstructured ways. Situation monitoring happened during routines, such as running the list, and led to creating a plan of patient care through shared decision-making. Some leadership characteristics were not exclusive to 1 team member. Finally, mutual support occurred through task completion and empowering learners; for example, attending physicians empowered senior residents, who also helped interns. CONCLUSIONS: Our findings aligned with some, but not all, teamwork principles from TeamSTEPPS; misalignment may be due to contextual factors, such as the need to provide medical education and the development of grassroots routines (eg, running the list). Context is a key consideration when developing interventions to enhance teamwork on inpatient medical wards.

Pediatric Rheumatology Curriculum for the Pediatrics Resident: A Case-Based Approach to Learning.

Introduction: Pediatric rheumatologic disease occurs more frequently than several other chronic pediatric diseases but is often underrecognized. It is estimated that in the US, one in 250 children has some form of juvenile arthritis and 300,000 children have a form of rheumatologic disease. However, there are only approximately 400 practicing pediatric rheumatologists nationwide. Methods: Kern's six-step method was used to develop a pediatric rheumatology curriculum based on respondents' perceived lack of training and comfort with four key areas: workup, musculoskeletal exam, laboratory interpretation, and referral to rheumatology. These cases were developed for second-year pediatric and second- and third-year internal medicine-pediatric residents rotating with the service. The curriculum was composed of four 30-minute case discussions as well as an observed musculoskeletal exam session. Results: In 2017, weekly case study sessions reached 34 trainees. Survey results from these trainees are representative of our overall results and reveal that learners felt the content of the cases helped increase comfort with compiling pertinent history and information of symptoms consistent with autoimmune disease, recognizing physical exam findings of autoimmune disease, ordering and interpreting laboratory studies in children with concerns for autoimmune disease, and referring to pediatric rheumatology. Discussion: This case-based curriculum exposed residents to presentations of the more common autoimmune diseases encountered in the pediatric population. The curriculum helps fill a gap in pediatric training through increased exposure to this subset of chronic diseases and expands physical examination skills not typically taught in general pediatrics.

An Examination of Physician-, Caregiver-, and Disease-Related Factors Associated With Readmission From a Pediatric Hospital Medicine Service.

OBJECTIVES: The purpose of this study was to describe the characteristics and reasons for pediatric hospital medicine readmissions. We also aimed to describe characteristics of potentially preventable cases and the reliability of classification. METHODS: Retrospective descriptive study from December 2008 through June 2010 in a large academic tertiary care children's hospital in Houston, Texas. Children were included if they were readmitted to the hospital within 30 days of discharge from the pediatric hospital medicine service. Reasons for readmission were grouped into three categories: physician-related, caretaker-related, and disease-related. Readmissions with physician- or caretaker-related reasons were considered potentially preventable. RESULTS: The overall readmission rate was 3.1%, and a total of 204 subjects were included in the analysis. Lymphadenitis and failure to thrive had the highest readmission rates with 21%, and 13%, respectively. Twenty percent (n=41/204) of readmissions were preventable with 24% (n=10/41) being physician-related, 12% (n=5/41) caregiver-related, and 63% (n=26/41) for mixed reasons. When comparing classification of readmissions into preventable status, there was moderate agreement between 2 reviewers (K=0.44, 95% confidence interval: 0.28-0.60). Among patients with preventable readmission, the probability of having had a readmission by 7 days and 15 days was 73% and 78%, respectively. CONCLUSIONS: Reliable identification of preventable pediatric readmissions using individual reviewers remains a challenge. Additional studies are needed to develop a reliable approach to identify preventable readmissions and underlying modifiable factors. A focused review of 7-day readmissions and diagnoses with high readmission rates may allow use of fewer resources.