Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice.

INTRODUCTION: Neonatal hyperbilirubinemia (NH) is commonly diagnosed and managed by pediatricians in various clinical settings. The 2004 American Academy of Pediatrics (AAP) Clinical Practice Guideline on NH is widely cited, but literature examining variation across pediatric specialties is limited. This study aimed to assess baseline knowledge and practice habits regarding NH among pediatric providers across various specialties immediately prior to the release of the 2022 NH clinical practice guideline. METHODS: A non-probability, convenience, self-selected sampling survey was electronically distributed to 311 subjects across five specialties within one pediatric healthcare institution. The survey included eight multiple choice knowledge-based questions with confidence assessments and five management-based questions assessing respondent agreement on a 5-point scale. To compare groups, the Kruskal-Wallis and Mann-Whitney tests were used for continuous variables, and the chi-square and Fisher's exact tests were used for categorical variables. RESULTS: The overall survey response rate is 46%. There were significant differences between specialties' knowledge regarding NH (p<0.05). There were also significant differences between specialties' confidence ratings, independent of choosing the correct response (p<0.05). For select management-based questions, there were also significant differences between specialties (p<0.05). A majority of respondents (56%) indicated phototherapy treatment thresholds should remain the same in updated management guidelines. CONCLUSIONS: Significant variations in knowledge and management of NH were identified among pediatric specialties. This suggests dissemination of new guidelines must be cognizant of different constraints impacting knowledge and practice across specialties.

Addressing drivers of healthcare utilization for neonatal opioid withdrawal syndrome.

OBJECTIVE: Aim to reduce healthcare utilization (HU) for infants at risk of neonatal opioid withdrawal syndrome (NOWS) by 30% in 1 year and sustain for 2 years. STUDY DESIGN: Baseline data from three Level I & II newborn nurseries from January 2016 to June 2018 informed PDSA cycles from August 2018 to December 2021. Shewhart process control charts evaluated length of stay (LOS), pharmacologic treatment (PT) rates, direct cost (DC), process, and balancing measures for special cause variation (SCV). RESULTS: Two hundred and seventeen infants showed downward SCV in LOS (12.6 to 4.4 days), PT (53% to 17%) and DC ($12593.82 to $5219.17). Onset of the COVID-19 pandemic coincided with reversible SCV. DC varied by provider specialty. CONCLUSION: Transition from MFNASS to ESC led to decrease in healthcare utilization for infants at risk of NOWS. QI methodology identified persistent drivers of variability, including the COVID-19 pandemic and provider specialty.

Preparing Effective Narrative Evaluations for the Medical School Performance Evaluation (MSPE).

Introduction: In 2016, the AAMC Medical School Performance Evaluation (MSPE) Task Force issued recommendations to standardize the MSPE but did not address the quality of the written narratives in that document. Narrative evaluations are hampered by code words, polite rhetoric, and bias to the detriment of students. To address this, the AAMC's Group on Student Affairs and Group on Educational Affairs convened an expert group to consider the state of narratives in the MSPE and develop resources to improve their quality. Methods: A series of interactive workshops was developed and presented at an AAMC webinar and national meetings. A presentation outlining challenges and possible approaches to improvement was followed with large-group discussion and/or small-group breakout activity to analyze and improve upon sample clinical comments and create summary clerkship paragraphs. The initial webinar used polling questions and free-text prompts to gather feedback for future workshops. Anonymous survey responses were collected at the end of each subsequent workshop to determine perceived effectiveness and potential utility at participants' institutions. Results: Over 680 administrators, faculty, and staff participated in the webinar or in one of four national-level workshops. Respondents agreed that the modules would be useful in faculty development and wanted to replicate their learning at their own institutions for overall better impact on the quality of MSPE narratives. Discussion: This resource addresses an important gap in the medical education literature. A variety of stakeholders affirmed that these workshops have value in training writers to improve their narrative comments for the MSPE.

A novel faculty development tool for writing a letter of recommendation.

OBJECTIVE: Based on a national survey of program directors we developed a letter of recommendation (LOR) scoring rubric (SR) to assess LORs submitted to a pediatric residency program. The objective was to use the SR to analyze: the consistency of LOR ratings across raters and LOR components that contributed to impression of the LOR and candidate. METHODS: We graded 30 LORs submitted to a pediatric residency program that were evenly distributed based on final rank by our program. The SR contained 3 sections (letter features, phrases, and applicant abilities) and 2 questions about the quality of the LOR (LORQ) and impression of the candidate (IC) after reading the LOR on a 5-point Likert scale. Inter-rater reliability was calculated with intraclass correlation coefficients (ICC(2,1)). Pearson (r) correlations and stepwise multivariate linear regression modeling predicted LORQ and IC. Mean scores of phrases, features, and applicant abilities were analyzed with ANOVA and Bonferroni correction. RESULTS: Phrases (ICC(2,1) = 0.82, p<0.001)) and features (ICC(2,1) = 0.60, p<0.001)) were rated consistently, while applicant abilities were not (ICC(2,1) = 0.28, p<0.001)). For features, LORQ (R2 = 0.75, p<0.001) and IC (R2 = 0.58, p<0.001) were best predicated by: writing about candidates' abilities, strength of recommendation, and depth of interaction with the applicant. For abilities, LORQ (R2 = 0.47, p<0.001) and IC (R2 = 0.51, p<0.001) were best predicted by: clinical reasoning, leadership, and communication skills (0.2). There were significant differences for phrases and features (p<0.05). CONCLUSIONS: The SR was consistent across raters and correlates with impression of LORQ and IC. This rubric has potential as a faculty development tool for writing LORS.

Pediatric, Surgery, and Internal Medicine Program Director Interpretations of Letters of Recommendation.

PURPOSE: Literature describing program director (PD) perceptions of letters of recommendation (LORs) and "code" used by letter writers is limited. In 2016, a survey instrument was distributed nationally to pediatric PDs asking them to rate their interpretations of components of LORs. The results confirmed that letter phrases convey code, but these results were not known to be generalizable outside of pediatrics. The purpose of this study was to expand the survey to surgery and internal medicine (IM) PDs looking for areas of agreement or variation between the 3 specialties. METHOD: The survey was sent nationally to surgery and IM PDs asking them to rate LORs in 3 areas on a 5-point Likert scale: 14 commonly used phrases, 13 letter features, and 10 applicant abilities. The LOR phrases were grouped using principal component analysis (PCA). Mean scores of components were analyzed with repeated-measures analysis of variance. RESULTS: Response rates: pediatrics 43% (486 of 1079), surgery 55% (151 of 277), and IM 42% (170 of 408). PCA generated groups of positive, neutral, and negative phrases with moderate to strong correlation with each other for all 3 specialties. There were significant differences between the mean Likert scores of the positive, neutral, and negative groups of phrases for all 3 specialties (all P < .001). "Showed improvement" was rated the most negative phrase by all 3 specialties. CONCLUSIONS: Key elements of LORs include distinct phrases depicting different degrees of endorsement of candidates. Pediatric, surgery, and IM PDs interpret letter components differently.

Dear Program Director: Deciphering Letters of Recommendation.

BACKGROUND: Letters of recommendation (LORs) are an important part of applications for residency and fellowship programs. Despite anecdotal use of a "code" in LORs, research on program director (PD) perceptions of the value of these documents is sparse. OBJECTIVE: We analyzed PD interpretations of LOR components and discriminated between perceived levels of applicant recommendations. METHODS: We conducted a cross-sectional, descriptive study of pediatrics residency and fellowship PDs. We developed a survey asking PDs to rate 3 aspects of LORs: 13 letter features, 10 applicant abilities, and 11 commonly used phrases, using a 5-point Likert scale. The 11 phrases were grouped using principal component analysis. Mean scores of components were analyzed with repeated-measures analysis of variance. Median Likert score differences between groups were analyzed with Mann-Whitney U tests. RESULTS: Our survey had a 43% response rate (468 of 1079). "I give my highest recommendation" was rated the most positive phrase, while "showed improvement" was rated the most negative. Principal component analysis generated 3 groups of phrases with moderate to strong correlation with each other. The mean Likert score for each group from the PD rating was calculated. Positive phrases had a mean (SD) of 4.4 (0.4), neutral phrases 3.4 (0.5), and negative phrases 2.6 (0.6). There was a significant difference among all 3 pairs of mean scores (all P < .001). CONCLUSIONS: Commonly used phrases in LORs were interpreted consistently by PDs and influenced their impressions of candidates. Key elements of LORs include distinct phrases depicting different degrees of endorsement.

Team-based learning on a third-year pediatric clerkship improves NBME subject exam blood disorder scores.

PURPOSE: At our institution, speculation amongst medical students and faculty exists as to whether team-based learning (TBL) can improve scores on high-stakes examinations over traditional didactic lectures. Faculty with experience using TBL developed and piloted a required TBL blood disorders (BD) module for third-year medical students on their pediatric clerkship. The purpose of this study is to analyze the BD scores from the NBME subject exams before and after the introduction of the module. METHODS: We analyzed institutional and national item difficulties for BD items from the NBME pediatrics content area item analysis reports from 2011 to 2014 before (pre) and after (post) the pilot (October 2012). Total scores of 590 NBME subject examination students from examinee performance profiles were analyzed pre/post. t-Tests and Cohen's d effect sizes were used to analyze item difficulties for institutional versus national scores and pre/post comparisons of item difficulties and total scores. RESULTS: BD scores for our institution were 0.65 (± 0.19) compared to 0.62 (± 0.15) nationally (P = 0.346; Cohen's d = 0.15). The average of post-consecutive BD scores for our students was 0.70 (± 0.21) compared to examinees nationally [0.64 (± 0.15)] with a significant mean difference (P = 0.031; Cohen's d = 0.43). The difference in our institutions pre [0.65 (± 0.19)] and post [0.70 (± 0.21)] BD scores trended higher (P = 0.391; Cohen's d = 0.27). Institutional BD scores were higher than national BD scores for both pre and post, with an effect size that tripled from pre to post scores. Institutional BD scores increased after the use of the TBL module, while overall exam scores remained steadily above national norms. CONCLUSIONS: Institutional BD scores were higher than national BD scores for both pre and post, with an effect size that tripled from pre to post scores. Institutional BD scores increased after the use of the TBL module, while overall exam scores remained steadily above national norms.

Streptococcus infection in a newborn.

Streptococcus salivarius is an uncommon cause of infection in neonates. Normally present in the oral flora of humans, S salivarius is the least pathogenic member of the viridans group streptococci and is often considered a contaminant when detected on blood culture. While rare, it has been shown in the literature to cause clinically relevant bacteremia and other invasive infections typically in the immunocompromised. We report the case of a well-appearing 1-day-old female with sequential positive blood cultures for S salivarius. This case has important implications as it demonstrates that S salivarius should not be automatically ruled out as a contaminant when isolated on blood culture.