Pediatric Resident and Program Director Views on Climate Change and Health Curricula: A Multi-Institution Study.

PURPOSE: The American Academy of Pediatrics emphasized in a 2007 policy statement the importance of educating trainees on the impacts of climate change on children's health, yet few studies have evaluated trainee knowledge and attitudes about climate change-related health effects in children. This multi-institution study assessed pediatric resident and program director (1) knowledge/attitudes on climate change and health, (2) perspectives on the importance of incorporating climate and health content into pediatric graduate medical education, and (3) preferred topics/activities to include in climate and health curricula. METHOD: This mixed-methods study employed an anonymous cross-sectional survey of pediatric residents and residency program directors from Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN)-affiliated programs. Multivariable regression models and factor analyses were used to examine associations among resident demographics and resident knowledge, attitudes, and interest in a climate change curriculum. A conventional content analysis was conducted for the open-ended responses. RESULTS: Eighteen programs participated in the study with all program directors (100% response rate) and 663 residents (average response rate per program, 53%; overall response rate, 42%) completing respective surveys. Of the program directors, only 3 (17%) felt very or moderately knowledgeable about the association between climate change and health impacts. The majority of residents (n=423, 64%) agreed/strongly agreed that physicians should discuss global warming/climate change and its health effects with patients/families, while only 138 residents (21%) agreed/strongly agreed that they were comfortable talking with patients and families about these issues. Most residents (n=498, 76%) and program directors (n=15, 83%) agreed/strongly agreed that a climate change curriculum should be incorporated into their pediatrics training program. CONCLUSIONS: Pediatric residents and program directors support curricula that prepare future pediatricians to address the impact of climate change on children's health; however, few programs currently offer specific training, despite identified needs.

"The curriculum brings equity to the forefront": Pediatric residents' perspectives and experiences in a longitudinal EDI curriculum.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements include training in caring for diverse populations and understanding social determinants of health. Our large pediatric residency program implemented a longitudinal equity, diversity and inclusion (EDI) curriculum. OBJECTIVE: To explore pediatric residents' perspectives and experiences in our longitudinal EDI curriculum. METHODS: We applied the holistic framework by Haji et al. to characterize the effect of our EDI curriculum. We conducted 4 focus groups from November 2019 to September 2020 with trained facilitators using a structured question guide. We approached all eligible senior residents (n = 87) via email to participate. Project members coded written notes and transcripts and analyzed data using inductive thematic analysis. RESULTS: 26 pediatric senior residents participated either in person (n = 13) or online (n = 13). Themes emerged from domains of knowledge, attitudes and behavioral change. These included having: (1) increased knowledge surrounding EDI issues, (2) a framework and language to better engage in EDI efforts and (3) increased confidence interrupting bias and microaggressions. Additional themes demonstrated: an increased need for EDI education at the institutional level, the unique experiences of Black, Indigenous, People of Color (BIPOC) trainees, and systemic barriers to equitable care. CONCLUSION: A longitudinal EDI curriculum has the potential to influence individual trainees, their work, and perceptions of the broader institutions in which they operate. Residents recognized and valued the curriculum and felt driven to use this knowledge to ensure that institutional policies and practices led to equitable clinical care.

The Effects of Coaching Pediatric Residents on Faculty Coaches' Relationships, Learning, and Professional Identity Formation.

PURPOSE: Coaching programs have been implemented in medical education to improve skill development and feedback for trainees. As more faculty take on coaching roles, it is critical to understand how being a coach affects faculty as well as trainees. This study examined the effects of coaching residents on faculty members' relationships, learning, and professional identity formation (PIF), as they move through intersecting communities across landscapes of practice. METHOD: From July 2020 to January 2021, the authors conducted a mixed-methods study of current and former coaches at 2 institutions with longitudinal pediatric resident coaching programs. They used a concurrent triangulation design in which qualitative and quantitative data were collected simultaneously and integrated during data analysis. A survey explored the impact of coaching on faculty members' learning, relationships, and PIF, and semistructured interviews further examined coaches' experiences. The interview transcripts were analyzed inductively guided by the sensitizing principles of PIF and landscapes of practice. RESULTS: Of 43 eligible coaches, 32 (74%) completed the survey, and 18 completed interviews. Four themes emerged from the interviews. (1) Coaches' relationships supported belonging in multiple communities. (2) Coaching enabled multidimensional learning. (3) Relationships served as mechanisms of learning for coaches. (4) Coaches' relationships and learning catalyzed PIF. Furthermore, there was a significant difference in the effects of coaching on career growth by faculty rank ( P = .02). Coaches' strengthened PIF increased a sense of purpose, meaning, and professional fulfillment, and inspired new career directions. Survey data further supported these findings. CONCLUSIONS: Being a coach deepened faculty members' professional identities through their varied relationships, multidimensional learning, and sense of belonging in intersecting communities. This study introduces a framework to understand the factors mediating coaches' PIF and highlights how investing in coaching leads to important benefits for coaches.

Description of a novel curriculum on equity, diversity and inclusion for pediatric residents.

BACKGROUND: Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training. METHODS: A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content. RESULTS: 109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ "eye opening" content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues. CONCLUSIONS: The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.

Pediatric Resident Perspectives on the Impact of COVID-19 on Training.

OBJECTIVES: At the onset of the coronavirus disease 2019 pandemic, disruptions to pediatric care and training were immediate and significant. We sought to understand the impact of the pandemic on residency training from the perspective of pediatric residents. METHODS: We conducted a cross-sectional survey of categorical pediatric residents at US training programs at the end of the 2019-2020 academic year. This voluntary survey included questions that explored the impact of the coronavirus disease 2019 pandemic on resident training experiences, postresidency employment plans, and attitudes and perceptions. Data were analyzed by using descriptive statistics and mixed-effects regression models. We performed a sensitivity analysis using respondents from programs with a >40% response rate for questions regarding resident attitudes and perceptions. RESULTS: Residents from 127 of 201 training programs (63.2%) completed the survey, with a response rate of 18.9% (1141 of 6032). Respondents reported multiple changes to their training experience including rotation schedule adjustments, clinic cancellations, and an increase in the use of telemedicine. Respondents also reported inconsistent access to personal protective equipment and increased involvement in the care of adult patients. Graduating resident respondents reported concerns related to employment. Respondents also noted a negative impact on their personal wellness. CONCLUSIONS: Responding residents reported that nearly every aspect of their training was impacted by the pandemic. Describing their experiences may help residency program and hospital leaders supplement missed educational experiences, better support residents through the remaining months of the pandemic, and better prepare for extraordinary circumstances in the future.

Assessing 5-Year Outcomes of an Academic Pediatrics-Community Partnership Focused on Rural Child Health.

BACKGROUND: The Resident Education in Advocacy and Child Health (REACH) pathway at a large academic pediatric residency program in the Northwest includes an academic-community partnership in a rural community. Few academic-community partnership evaluations have focused on community values. REACH trainees conducted a 5-year evaluation of the partnership using community-generated outcomes measures. We sought to 1) apply community-based participatory research (CBPR) principles to engage community stakeholders, 2) mutually develop program evaluation measures, and 3) describe core projects and the community's perceptions of the REACH program. A secondary objective was to evaluate REACH pathway influence on trainee alumni. METHODS: We used a community-informed design to determine outcomes and indicators, 2) gathered data through iterative review of materials, stakeholder interviews, and alumni surveys, and 3) conducted a quantitative and qualitative analysis and synthesis. RESULTS: Four short-term outcomes measures were identified for a logic model: 1) project sustainability, 2) direct engagement with youth, 3) Community partnerships, and 4) "ripple effects." Of non-foundational projects, 50% were sustained at the time of the evaluation. Fourteen projects (70%) engaged youth. At least five ongoing community partnerships were identified. Four stakeholders (24%) noted a ripple effect. Trainee alumni reported increased confidence in research skills, cultural competence, and appreciation of community perspectives. Key themes of the partnership's value were relationships, outsider perspective and professional expertise, trainees as catalyst, and balance of research with action. CONCLUSIONS: Our evaluation demonstrated the partnership's value to community and trainees and yielded suggestions for increasing the program's impact. We believe that key elements of this evaluation could be used in other academic-community partnership programs.

Grounded in Justice: An Equity Framework for Chief Residents.

The 2019-2020 academic year was unprecedented, with navigating the COVID-19 pandemic and meaningfully engaging with the causes and consequences of long-standing racism and social injustice in the United States. In this article, the authors, all former chief residents, reflect on how they carried out their role during this last year using an approach that was grounded in equity and justice. They describe a framework based on their experiences, including setting the tone and culture of the residency program; providing medical education, teaching, and feedback; advocating for resident well-being and inclusion; participating in quality improvement and hospital policymaking; and partnering for institutional change. They end with a call to action to reconceptualize the role of the chief resident to include the genuine work of diversity, equity, and inclusion to ensure a more equitable future.

Perspectives of Caregivers on the Effects of Migration on the Nutrition, Health and Physical Activity of their Young Children: A Qualitative Study with Immigrant and Refugee Families.

To explore perspectives on nutrition, health and physical activity among immigrant parents with young children before and after migration. We conducted focus groups in five languages (Arabic, Somali, Dari, Burmese and Nepali), then conducted a phenomenological analysis of the transcripts. Fifty caregivers participated; 42% spent time in a refugee camp. Within the domain Change in Environment, four themes emerged: (1) food access; (2) family experiences with weight and growth; (3) differences in physical activity and perceptions of safety; and (4) health care experience. Within the domain of Parenting Behaviors and Experiences, two themes emerged: (1) Sociocultural differences in early feeding behaviors and (2) concern about feeding behaviors. To support health outcomes for refugee and immigrant families with young children, key focus areas for programming would include access to fresh foods, safe places for physical activity, and feeding practices following a family history of food scarcity.

Understanding physician burnout.

Physician well-being is associated with benefits for physicians, patients, and health care systems. Well-being encompasses many inter-related attributes, including but not limited to resilience, fulfillment, joy in work, and burnout. Among these, burnout has been studied most widely, and has been found to be more frequent among medical trainees and professionals than in the general population. Burnout has been associated with physician depression and suicidality, which are also more frequent among physicians than the general population. The negative effects of burnout include decreased patient satisfaction, increased medical errors, and increased costs. Physician burnout has been associated with both organization-level drivers that contribute to an imbalance between resources and workload for physicians, and individual-level drivers related to resilience practices and attitudes. This paper reviews the literature on the epidemiology, drivers, and implications of physician burnout.

Medical Home-Head Start Partnership to Promote Early Learning for Low-Income Children.

OBJECTIVE: To improve Early Head Start/Head Start (EHS/HS) screening, referral, and enrollment for children from diverse, low-income communities. METHOD: Using existing resources, we built a pediatric clinic-Head Start partnership. Key steps included (1) screening protocol and tracking system, (2) a community partner as a single point of referral contact, (3) provider education, and (4) monthly outcome reporting. A pre- and post-cross-sectional study design was used to evaluate outcomes, with medical chart review conducted for all wellness visits among children aged 0 to 4 years pre- and postintervention. RESULTS: The preintervention group included 223 patients. The postintervention group included 235 patients. EHS/HS screening improved significantly after the intervention, rising from 8% in the preintervention period to 46% in the postintervention period (odds ratio [OR] 10.5, 95% confidence interval [CI] [5.9, 19.4]). EHS/HS documented referral rates increased from 1% in the preintervention period to 20% in the postintervention period (OR 18.3, 95% CI [5.7, 93.6]). Thirty-two of the 42 patients in the postintervention group referred to EHS/HS were reached to determine enrollment status. Six children (14%) had enrolled in EHS/HS. CONCLUSION: With use of existing resources, a medical home-Head Start partnership can build an integrated system that significantly improves screening and referral rates to early learning programs.

Training Pediatricians to Address Health Disparities: An Innovative Residency Track Combining Global Health With Community Pediatrics and Advocacy.

PROBLEM: Pediatric residency programs have been tasked to train a workforce of pediatricians with skills in community pediatrics (CP) and advocacy, and knowledge of global child health priorities. APPROACH: In 2009, the University of Washington (UW) Seattle Children's Hospital pediatric residency program developed the Resident Education in Advocacy and Child Health (REACH) program, a combined pathway for global health (GH) and CP training. After participating in a combined curriculum, residents complete a community immersion either in Kisii, Kenya (GH) or rural Washington (CP). This approach provides an efficient use of faculty and administrative resources and delivers a sustainable and ethical strategy for inspiring pediatric residents to address child health problems at a systems level. OUTCOMES: Between 2009 and 2013, the percentage of graduating residents from the UW pediatric residency program who rated GH training as "outstanding/excellent/good" increased from 58.4% to 100%, and the percentage rating community and population health training as "outstanding/excellent/good" increased from 56% to 88.8%. Annual applicant surveys in the period 2011-2014 revealed that the REACH program led a significant percentage of candidates to rank the UW pediatric residency more favorably because of its GH (37%-48%) and CP (55%-74%) training. NEXT STEPS: A mixed-methods assessment will evaluate the impact on resident confidence in core areas of community health and advocacy including collaborating with community groups, setting professional career goals, addressing underlying determinants of health during patient encounters, communicating in cross-cultural settings, and advocating for child health. A survey will assess outcomes on graduates' careers.

Growth Trajectories of Refugee and Nonrefugee Children in the United States.

BACKGROUND AND OBJECTIVES: Limited data examine longitudinal nutrition outcomes of refugee children after United States resettlement. Among refugee children, our aims were to (1) assess the changes in weight-based nutritional status between baseline (0-3 months) and 10-24 months after arrival and (2) compare the BMI (BMIz) or weight-for-length z score (WFLz) trajectories to nonrefugee children for up to 36 months after arrival. METHODS: We conducted a retrospective study of refugees aged 0-16 years from Washington and Pennsylvania and compared them with an age and sex-matched nonrefugee low-income sample from Washington. Data included anthropometric measurements from the initial screening medical visit and subsequent primary care visits. Multilevel linear mixed-effects regression models evaluated the change in BMIz or WFLz trajectory. RESULTS: The study included 512 refugee and 1175 nonrefugee children. The unadjusted prevalence of overweight/obesity increased from 8.9% to 20% (P < .001) for 2- to 16-year-old refugees from baseline to 10-24 months. Refugees (2-16 years old) had a steeper increase in their BMIz per 12 months compared with nonrefugees (coefficient 0.18 vs 0.03; P < .001). Refugees <2 years old had a less steep increase in their WFLz per 12 months compared with nonrefugees (coefficient 0.12 vs 0.36, P = .002). CONCLUSIONS: Older refugee children exhibited a higher risk of obesity than nonrefugees, whereas refugees <2 years old exhibited a slower increase in their risk of obesity than nonrefugee children. All age groups experienced increasing obesity prevalence. Targeted and culturally tailored obesity prevention interventions may mitigate health and nutrition inequities among refugee children.

Characterizing Key Components of a Medical Home Among Rural Adolescents.

PURPOSE: Adolescents in rural areas have higher unmet medical needs and receive fewer preventive health care visits than their urban counterparts. This community health assessment aimed to describe adolescent experiences of key components of a medical home in rural Washington. METHODS: A cross-sectional survey using questions from two validated measures was created with input from a community advisory group using community-based participatory research principles. The survey was administered to a convenience sample of high-school students in one rural town. Responses within each medical home domain were grouped to create composite scores. Linear and logistic regression analyses identified characteristics associated with receiving medical home services. RESULTS: A total of 217 adolescents aged 13-19 years completed the survey. Eighty-five percent identified as Latino/Hispanic. Respondents described usually or always feeling listened to by providers (80%), respected by providers (89%), and welcomed at their clinic (79%). Fewer reported having a personal health provider (56%), meeting alone with a provider (56%), or knowing the visit was confidential (60%). Those who identified having a primary provider had 2.48 greater odds (95% confidence interval = 1.13-5.45) of reporting a well visit in the previous year and had higher composite scores for compassionate and patient-centered care. CONCLUSIONS: This sample of rural adolescents reported receiving many characteristics of a medical home but had limited experience with personal providers and confidential services. Improving adolescent access to confidential care may be especially important in small, rural communities. The association of a primary provider with improved medical home experience highlights this key characteristic in an adolescent medical home.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group.

BACKGROUND: There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER). METHODS: Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities. RESULTS: Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0). CONCLUSIONS: Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Everyone Swims: a community partnership and policy approach to address health disparities in drowning and obesity.

Well-known disparities exist in rates of obesity and drowning, two public health priorities. Addressing these disparities by increasing access to safe swimming and water recreation may yield benefits for both obesity and injury prevention. Everyone Swims, a community partnership, brought community health clinics and water recreation organizations together to improve policies and systems that facilitated learning to swim and access to swimming and water recreation for low-income, diverse communities. Based in King County, Washington, Everyone Swims launched with Centers for Disease Control and Prevention grant funding from 2010 to 2012. This partnership led to multiple improvements in policies and systems: higher numbers of clinics screening for swimming ability, referrals from clinics to pools, more scholarship accessibility, and expansion of special swim programs. In building partnerships between community health/public health and community recreation organizations to develop systems that address user needs in low-income and culturally diverse communities, Everyone Swims represents a promising model of a structured partnership for systems and policy change to promote health and physical activity.

Addressing prediabetes in childhood obesity treatment programs: support from research and current practice.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and prediabetes have increased in prevalence among overweight and obese children, with significant implications for long-term health. There is little published evidence on the best approaches to care of prediabetes among overweight youth or the current practices used across pediatric weight management programs. METHODS: This article reviews the literature and summarizes current practices for screening, diagnosis, and treatment of prediabetes at childhood obesity treatment centers. Findings regarding current practice were based on responses to an online survey from 28 pediatric weight management programs at 25 children's hospitals in 2012. Based on the literature reviewed, and empiric data, consensus support statements on prediabetes care and T2DM prevention were developed among representatives of these 25 children's hospitals' obesity clinics. RESULTS: The evidence reviewed demonstrates that current T2DM and prediabetes diagnostic parameters are derived from adult-based studies with little understanding of clinical outcomes among youth. Very limited evidence exists on preventing progression of prediabetes. Some evidence suggests that a significant proportion of obese youth with prediabetes will revert to normoglycemia without pharmacological management. Evidence supports lifestyle modification for children with prediabetes, but further study of specific lifestyle changes and pharmacological treatments is needed. CONCLUSION: Evidence to guide management of prediabetes in children is limited. Current practice patterns of pediatric weight management programs show areas of variability in practice, reflecting the limited evidence base. More research is needed to guide clinical care for overweight youth with prediabetes.

Physical and social home environment in relation to children's overall and home-based physical activity and sedentary time.

BACKGROUND: Given the obesity epidemic, it is critical to understand factors associated with youth physical activity and sedentary behavior at home, where youth spend significant time. We examined relationships between these child behaviors and home environment factors. METHODS: Data were obtained from 713 children aged 6 to 11 in Washington and California 2007-2009. Multivariate regression analyses controlling for socio-demographics examined associations between parent-reported home environment factors and child's accelerometer-measured moderate-to-vigorous physical activity (MVPA) and sedentary time, overall and at home, and parent-reported child screen time. RESULTS: Children averaged 47.2% of time at home, which included 43.6% and 46.4% of overall MVPA and sedentary behavior, respectively. Parental support for physical activity and having a basketball hoop were positively associated with MVPA and negatively associated with sedentary behavior. Combined parental support and a basketball hoop was associated with even higher MVPA. Children with fewer bedroom media devices and more fixed play equipment had lower overall sedentary behavior and screen time than either factor alone. Findings were similar regardless of weight status. CONCLUSIONS: Physical and social home environment variables, especially when combined, were related to more child MVPA and less sedentary behavior. Results support addressing multiple home environment factors in childhood obesity prevention.

Partnering for success and sustainability in community-based child obesity intervention: seeking to help families ACT!

Sustaining community-based obesity interventions for families represents an ongoing challenge. Many initially grant-funded initiatives lack a sustainable model to continue. After initial grant funding ended, we continued a partnership between Seattle Children's Hospital and YMCA of Greater Seattle to enhance and expand a community-based family obesity program, "ACT! Actively Changing Together." We used principles of continuous process improvement, community-based participatory research, and the RE-AIM framework to successfully transition from a grant-funded to a community-supported program. Our pilot evaluation demonstrated promising results in parent behaviors, youth quality of life, ongoing family participation at the Y, and youth body mass index.