When and how pediatric history and physical diagnosis are taught in medical school: a survey of pediatric clerkship directors.

BACKGROUND: [corrected] History and physical diagnosis skills (HPDS) are required curriculum in medical schools (MS) with pediatric HPDS (PHPDS) necessitating instruction in addition to adult HPDS. Perceived deficiencies in these skills on the pediatric clerkship prompted investigation of when and how other MS taught PHPDS. The concern of whether medical students are adequately taught PHPDS needed to be addressed. METHODS: With the use of the Council on Medical Student Education in Pediatrics listserv, pediatric clerkship directors from 129 US, 15 Canadian, and 2 Puerto Rican MS were contacted via e-mail to complete an anonymous online questionnaire, focused on MS demographics, PHPDS timing, teaching methods, and barriers. RESULTS: Seventy-two (49%) of 146 MS responded to the survey; 18.1% of MS responders did not offer PHPDS in the first 2 years. Methodologies used to educate students included didactic lectures, physician shadowing, hands-on with patients, pairing with preceptor, instructional video, and examination of newborns. Each teaching method had < 3 hours dedicated to medical students during their first 2 years at a majority of the MS. Of the responders, 85.1% concurred that medical students should be exposed to PHPDS before starting the clerkship. Barriers to providing PHPDS included MS time allotment, preceptor availability, and total number of students to accommodate. CONCLUSIONS: This study demonstrated striking variability among MS in how and when medical students were taught PHPDS. Clarification of the role of PHPDS instruction in preclinical years and standardized effective approaches to PHPDS instruction are both needed so that MS curriculum optimizes physician training.

Development of a gastroenterology educational curriculum for pediatric residents using fellows as teachers.

OBJECTIVES: At many institutions, the teaching provided on subspecialty gastroenterology rotations is not structured. The purpose of the present study was to describe the development, implementation, and assessment of a structured gastroenterology curriculum for pediatric residents. METHODS: A needs assessment was performed via a survey of former pediatric resident graduates presently working in general pediatrics. Topics for the curriculum were developed based upon the needs assessment. Second-year residents on the inpatient gastroenterology rotation attended 4 case-based, small group sessions per week for 1 month. Sessions were taught primarily by upper-level gastroenterology fellows. The curriculum was assessed via a pre-posttest, postrotation survey, and group feedback sessions. RESULTS: Resident rating of education received during the rotation was high. Posttest scores increased slightly but significantly compared with pretest values. The curriculum has continued to be used >4 years after its development. CONCLUSIONS: The creation of a structured subspecialty curriculum with the use of fellows as teachers is both feasible and effective despite limitations in available time for resident teaching.

Improving peppermint essential oil yield and composition by metabolic engineering.

Peppermint (Mentha × piperita L.) was transformed with various gene constructs to evaluate the utility of metabolic engineering for improving essential oil yield and composition. Oil yield increases were achieved by overexpressing genes involved in the supply of precursors through the 2C-methyl-D-erythritol 4-phosphate (MEP) pathway. Two-gene combinations to enhance both oil yield and composition in a single transgenic line were assessed as well. The most promising results were obtained by transforming plants expressing an antisense version of (+)-menthofuran synthase, which is critical for adjusting the levels of specific undesirable oil constituents, with a construct for the overexpression of the MEP pathway gene 1-deoxy-D-xylulose 5-phosphate reductoisomerase (up to 61% oil yield increase over wild-type controls with low levels of the undesirable side-product (+)-menthofuran and its intermediate (+)-pulegone). Elite transgenic lines were advanced to multiyear field trials, which demonstrated consistent oil yield increases of up to 78% over wild-type controls and desirable effects on oil composition under commercial growth conditions. The transgenic expression of a gene encoding (+)-limonene synthase was used to accumulate elevated levels of (+)-limonene, which allows oil derived from transgenic plants to be recognized during the processing of commercial formulations containing peppermint oil. Our study illustrates the utility of metabolic engineering for the sustainable agricultural production of high quality essential oils at a competitive cost.

Welcome back? Frequent attenders to a pediatric primary care center.

This study examines frequent attenders of a pediatric primary care clinic at a large urban children's hospital--who they are and their reasons for frequent attendance to the clinic. The literature suggests that some visits by frequent attenders may not be medically necessary, and these additional appointments may impair others' access to medical care within the same system. The key to eliminating excessive primary care visits is to determine if it is a problem in the primary care practice (quantify the problem), explore the reasons for the visits (from the patients' perspective), and then provide educational interventions that address the various causes for the extra visits and encourage the use of available resources, either ancillary services in the practice itself or resources and agencies available in the community (e.g. social service, legal aid).

Training in social determinants of health in primary care: does it change resident behavior?

OBJECTIVE: The aim of this study was to examine the effects of a new social determinants of health curriculum on pediatric interns' attitudes, knowledge, documentation, and clinical practice. METHODS: A nonrandomized mixed-methods study of an educational intervention conducted over a 1-year period was performed. The 2008-2009 pediatric interns (intervention group) participated in a new social determinants of health curriculum; prior year interns were controls. An anonymous online survey at the end of internship to both groups (post-tests) and the beginning of internship to the intervention group (pretest) assessed attitudes and knowledge. Documentation from the electronic medical record of social history questions was audited during the same 3-month period in successive years. Medical-legal partnership (MLP) referrals from both groups were compared. RESULTS: Intervention interns (n = 20) were more comfortable discussing issues (100% vs. 71%; P < .01) and felt more knowledgeable regarding issues (100% vs. 64%; P = .005), community resources (94% vs. 29%; P < .001), and housing (39% vs. 6%; P = .04) than control group interns (n = 18). No differences regarding the importance of social hardships or screening for food security or education issues were found. Knowledge was greater in the intervention group post-test in all domains: benefits (72% vs. 52%), housing (48% vs. 21%), and education (52% vs. 33%; P < .001 for all). Intervention interns were more likely to document each issue (benefits 98% vs. 60%, housing 93% vs. 57%, food 74% vs. 56%; P < .001 for all). The intervention group had a slightly higher rate of referral to MLP, although the difference did not reach statistical significance. CONCLUSION: The educational intervention increased interns' comfort and knowledge of social determinants of health and community resources. Documentation of social questions also increased.

Parental Health Attributions of Childhood Health and Illness: Development of the Pediatric Cultural Health Attributions Questionnaire (Pedi-CHAQ).

The causes attributed to childhood health and illness across cultures (cultural health attributions) are key factors that are now more frequently identified as affecting the health outcomes of children. Research suggests that the causes attributed to an event such as illness are thought to affect subsequent motivation, emotional response, decision making, and behavior. To date, there is no measure of health attributions appropriate for use with parents of pediatric patients. Using the Many-Facets approach to Rasch analysis, this study assesses the psychometrics of a newly developed instrument, the Pediatric Health Attributions Questionnaire (Pedi-CHAQ), a measure designed to assess the cultural health attributions of parents in diverse communities. Results suggest acceptable Rasch model statistics of fit and reliability for the Pedi-CHAQ. A shortened version of the questionnaire was developed as a result of this study and next steps are discussed.

Development and testing of a CD-ROM program for improving adolescent knowledge of inflammatory bowel disease.

OBJECTIVE: The aim of this study was to design a theory-based educational program for adolescents with inflammatory bowel disease (IBD) using an interactive multimedia CD-ROM and to test its effectiveness in improving knowledge in IBD. MATERIALS AND METHODS: Curriculum-based instruction using educational theory and principles was designed for adolescents on an interactive multimedia CD-ROM. Twenty subjects completed summative evaluation of the CD-ROM measuring gain in knowledge about IBD immediately and 9 months after instruction. RESULTS: Subjects found the CD-ROM to be informative, appealing, and easy to use. The mean baseline score of the adolescents on the Crohn's and Colitis Knowledge questionnaire was 12.2 (standard deviation 5.14, range 3-24). After an average of 30 minutes of self-directed learning, adolescent subjects increased their posttest score to a mean of 19.8, a gain of 7.6 points over baseline (95% confidence interval 5.2-10.1, P < 0.0001). Knowledge of medications, disease complications, and gastrointestinal structure and function was gained and retained upon retesting at 9 months with a mean Crohn's and Colitis Knowledge questionnaire score of 17.5 (standard deviation 3.9, range 12-26), which was still an improvement over the mean pretest knowledge score of 12.2 (P < 0.001). CONCLUSIONS: Adolescents with IBD have low baseline knowledge about their disease. A rigorously developed interactive educational tool is now available for instructing adolescent patients about their IBD.

Teaching medical professionals online: a cross-discipline experience.

BACKGROUND: Teaching online and cross-discipline teaching are new experiences for many instructors. AIM: Our aim was to solicit the experiences of a group of College of Education faculty about teaching medical professionals in an online master's degree in education program. METHOD: We used a focus group approach (eight instructors) to explore and gain a deeper understanding about teaching medical professionals by instructors who are in cross disciplines (e.g., nonmedical backgrounds). RESULTS: The data were analyzed using a qualitative thematic analysis approach. Six themes emerged from the instructors' comments about online teaching to medical professionals compared with other students they have taught in a classroom setting. CONCLUSION: This study has implications for online teachers and for those who are planning cross-discipline teaching programs.

Effectiveness of an online pediatric primary care curriculum.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a supplementary online pediatric primary care (PPC) curriculum in reaching pediatric residents and increasing knowledge in selected primary care topics. METHODS: We conducted a nonrandomized, controlled, pre-test/post-test study comparing an online PPC curriculum supplement with the traditional formal, conference-based curriculum alone, both with identical content. We compared 2 groups of first-year categorical pediatric residents from 2 successive years: one group (from 2006-2007) was offered the online curriculum supplement (study group) and one (2005-2006) was not (control group). Comparisons were made using the following: 1) pre-testing and post-testing of knowledge; and 2) monitoring of attendance at the formal conferences and accessing the online curriculum. RESULTS: The control group of 33 residents and the study group of 34 residents were similar with respect to gender, age, and first-year in-training exam scores. In the first quarter of the year, 93% (mean) of the study group accessed the online curriculum; 43% accessed it in the last quarter of the year. For the same time periods, 33% and 30% of all of the residents (intervention and control groups combined) attended the noon conferences. The pre-test and post-test scores of the study group showed a significant increase (P < .001), and the post-test score comparison of study versus control group was also significant (P = .035). There were no significant differences in the in-training exam scores between the 2 groups for exams given at the beginning of their second year. CONCLUSION: An online PPC curriculum is an effective supplement to traditional resident education and reaches a significantly larger number of residents compared with the traditional conference-based format.

Reflective practice and competencies in global health training: lesson for serving diverse patient populations.

BACKGROUND: Resident interest in global health care training is growing and has been shown to have a positive effect on participants' clinical skills and cultural competency. In addition, it is associated with career choices in primary care, public health, and in the service of underserved populations. The purpose of this study was to explore, through reflective practice, how participation in a formal global health training program influences pediatric residents' perspectives when caring for diverse patient populations. METHODS: Thirteen pediatric and combined-program residents enrolled in a year-long Global Health Scholars Program at Cincinnati Children's Hospital Medical Center during the 2007-2008 academic year. Educational interventions included a written curriculum, a lecture series, one-on-one mentoring sessions, an experience abroad, and reflective journaling assignments. The American Society for Tropical Medicine and Hygiene global health competencies were used as an a priori coding framework to qualitatively analyze the reflective journal entries of the residents. RESULTS: Four themes emerged from the coded journal passages from all 13 residents: (1) the burden of global disease, as a heightened awareness of the diseases that affect humans worldwide; (2) immigrant/underserved health, reflected in a desire to apply lessons learned abroad at home to provide more culturally effective care to immigrant patients in the United States; (3) parenting, or observed parental, longing to assure that their children receive health care; and (4) humanitarianism, expressed as the desire to volunteer in future humanitarian health efforts in the United States and abroad. CONCLUSIONS: Our findings suggest that participating in a global health training program helped residents begin to acquire competence in the American Society for Tropical Medicine and Hygiene competency domains. Such training also may strengthen residents' acquisition of professional skills, including the Accreditation Council for Graduate Medical Education competencies.

Do different pairings of teaching styles and learning styles make a difference? Preceptor and resident perceptions.

BACKGROUND: Certain teaching style (TS) and learning style (LS) combinations may enhance learning. PURPOSE: The objective was to examine the effects of combinations of TS and LS in preceptor-resident (PR-RE) dyads in a long-term teaching-learning environment. METHODS: Forty-four pediatric PR-RE pairs responded to Grasha's TS and LS inventories, the Clinical Teacher Characteristics Instrument (CTCI) and the Preceptor-Resident Relationship Inventory (PRPRI). Combined CTCI and PRRI means were compared using the t test. RESULTS: The facilitator or personal model TS and collaborative LS pairs supported a healthy teaching-learning environment. Independent learners rated their preceptors' teaching characteristics positively. Competitive LS residents rated the relationship with the preceptor and preceptor teaching effectiveness less favorably. Residents overall indicated a less favorable relationship and clinical teaching characteristics than preceptors. CONCLUSIONS: Certain combinations of TS with LS are perceived by preceptors and residents as more positive than others. This suggests TS and LS should be considered when pairing residents and preceptors.

Online master's degree in education for healthcare professionals: early outcomes of a new program.

BACKGROUND: The Online Master's Degree in Education for Healthcare Professionals program, a collaboration of the University of Cincinnati Colleges of Medicine and Education, was launched nationally in 2002. The purpose of this survey-based, descriptive study was to describe the early outcomes of this new program. METHODS: Surveys were sent via email to 32 eligible students (students who have completed at least 6 of 12 required courses in the program) which included all 8 graduates. RESULTS: Based on 21 returns (66%) participants have had 19 journal publications, 99 national presentations, 13 teaching awards, 5 promotions, and acquisition of extramural funding for educational projects totaling over $3 million. CONCLUSIONS: Based on early results, graduates of the program are productive in academic medical education. We anticipate that graduates of the program will have a significant impact on medical education and will achieve promotion and advancement at their institutions.

Strengthening the academic base of general pediatrics fellowship programs: a national program and curriculum development project.

OBJECTIVE: To improve academic general pediatrics (AGP) fellowship programs by 1) developing curriculum guidelines and program standards and 2) creating a process for program review and consultation that might later be used for accreditation of AGP fellowship programs. METHODS: This project of the Ambulatory Pediatric Association (APA) created 4 documents: AGP fellowship program requirements, core curriculum, educational goals and objectives, and a standardized form to describe required program characteristics. Site visits were conducted at 7 volunteer AGP fellowship programs, selected for diversity of content, structure, and location. Evaluations were conducted using a uniform checklist of requirements that combined numerical ratings with a written evaluation summary. Feedback from programs on the review process enabled refinement of the documents. RESULTS: The site visits revealed great variety in emphasis among the 7 programs. In general, faculty were dedicated and capable, and programs showed considerable educational strengths. Typical problems were lack of integration of the program within departmental structures, overburdened faculty, and uncertain funding. Many programs demonstrated suboptimal curriculum planning and weak evaluation methods. Most program leaders felt that the project materials helped to improve the quality of their programs, and 5 of 7 programs expressed willingness to be involved in formal accreditation review in the future. CONCLUSIONS: AGP fellowship programs that volunteered for piloting of an accreditation process were diverse and vital, with rich educational offerings despite a lack of optimal curriculum structure, minimal evaluation, limited faculty resources, and tenuous funding. An APA accreditation process appears to be feasible and may enhance AGP fellowship programs.

Academic general pediatric fellowships: curriculum design and educational goals and objectives.

Academic generalists are unique and important members of the pediatric landscape.(1) Academic general pediatrics (AGP) is not considered a subspecialty, because it adheres to generalist values and embraces a wide range of clinical activities. Nonetheless, academic generalists engage in important scholarly efforts, contribute extensively to the education of new pediatricians, and must be prepared to survive in academia. Academic general pediatric faculty positions are subject to the same appointment and promotion requirements as those of subspecialist faculty.

Exam room presentations and teaching in outpatient pediatrics: effects on visit duration and parent, attending physician, and resident perceptions.

OBJECTIVE: To examine the effects of exam room presentations and teaching (ERPT) in a busy outpatient pediatric setting on visit duration and on parent, preceptor, and resident perceptions. METHODS: This 8-week, 2-method crossover study compared first-year pediatric resident patient presentations and attending physician teaching and discussion in the exam room (ERPT) with conference area presentation and teaching (CAPT). Outcome measures included visit duration, parent satisfaction, and resident/attending physician perceptions. Differences were analyzed using chi2 (parent surveys), t tests (visit duration), and signed rank tests (Attending Physician and Resident Surveys). RESULTS: Three hundred forty patient encounters were studied (151 ERPT vs 189 CAPT) that involved 15 first-year pediatric residents and 15 attending physicians. Visit durations were equivalent. Parent satisfaction was high in both methods. Attending physicians favored ERPT for adding opportunities to evaluate resident competencies, provide informed feedback, and role model. Attending physicians felt that ERPT decreased resident comfort level when discussing sensitive topics. Residents were less comfortable with ERPT for discussing sensitive topics and felt somewhat embarrassed when they did not know the answer to attending physicians' questions. Residents reported that ERPT presentations permitted attending physicians to demonstrate more physical exam skills and to observe interactions, enabling more informed feedback. CONCLUSIONS: ERPT and CAPT require similar time and result in high parent satisfaction. Although residents are a little less comfortable with ERPT, attending physicians are better able to observe, evaluate, and give feedback on resident skills and to role model and teach physical diagnosis.

The development of an electronic educational portfolio: an outline for medical education professionals.

BACKGROUND: A growing body of literature shows that many universities and colleges are making educational portfolios part of their faculty assessment and student's learning plan for both undergraduate and graduate programs. We provide an outline for the development of a medical educator's portfolio, including an electronic version. DESCRIPTION: Guidelines for the development of an educational portfolio focusing on medical education are provided, including design, format, and content. An electronic version of the portfolio, which combines flexibility and ease of revision, is also described, including formats for publication and distribution. Student reflections on the e-portfolio are presented, and potential applications of the e-portfolio in medical education are described. CONCLUSION: We believe that portfolio development is a valuable application that provides rich documentation of participants' educational history, accomplishments, and intellectual property as related to their professional learning and growth.

Variability in the management of childhood constipation.

To assist primary care providers, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published clinical practice guidelines for management of childhood constipation. A cross-sectional survey of pediatricians from across the United States was conducted to assess pediatricians' constipation management strategies, whether pediatricians are familiar with the NASPGHAN constipation guidelines, and reasons pediatricians refer constipated patients to a pediatric gastroenterologist. Overall, 75% of pediatricians used polyethylene glycol without electrolytes to treat childhood constipation, 8% of pediatricians were aware NASPGHAN had published constipation guidelines, and parental pressure was just one reason pediatricians referred constipated patients to a pediatric gastroenterologist.

Development and implementation of an online master's degree in education program for health care professionals.

Technological advances, especially the Internet and the World Wide Web, have drastically changed educational practices by reforming the concept of education and knowledge transmission at a distance. Professionals in all disciplines have begun using this advanced technology to expand the number of learning opportunities for intellectual growth and professional development. As a result, many universities and educational institutions now offer online higher degree programs to provide opportunities for nontraditional students who have difficulty attending scheduled, campus-based classes. In medicine, a need has been identified for advanced graduate studies in education to develop the next generation of medical educators and to train them in educational research methods to validate their educational efforts. This need was identified by both informal needs assessment at local, regional, and national faculty development meetings and more formal literature review and government survey. The faculty development team of Cincinnati Children's Hospital Medical Center (Department of Pediatrics, University of Cincinnati College of Medicine) collaborated with the College of Education to develop an online Master's Degree in Education for health care professionals. The program was designed to apply these advanced technologies in order to make the program flexible and accessible to health care professionals whose busy schedules preclude more traditional, in-class graduate programs. This article presents how this program evolved and the problems, challenges, and solutions associated with the development and implementation of the program.

Psychological size and distance: emphasising the interpersonal relationship as a pathway to optimal teaching and learning conditions.

BACKGROUND: Positive interpersonal relationships between teachers and learners increase the quality of learning. The purpose of this study was to investigate psychological size (perceived status) and psychological distance (perceived emotional connectedness) in medical teaching interactions and their impact on the teaching and learning process. METHOD: A total of 45 paediatric preceptor/resident pairs engaged in longitudinal continuity training experiences at different sites were surveyed about teaching effectiveness, satisfaction with teaching, and the psychological size and distance in the relationship between each pair. RESULTS: Both residents and preceptors perceived the resident as having a smaller psychological size compared to the preceptor. Residents perceived greater psychological distance in the relationship than did preceptors, and this distance was significantly related to both residents' satisfaction with particular preceptors and their perception of the preceptors' effectiveness. CONCLUSIONS: Psychological size and distance contribute to effective and satisfactory teaching. Investigating additional aspects of the teaching-learning relationship should help identify optimal educational conditions.

Naltrexone in the treatment of alcohol dependence: a Canadian trial.

OBJECTIVES: Alcohol dependence is a prevalent psychiatric disorder affecting approximately 12% of the adult population at some point in their lifetime. Psychosocial treatments are associated with only modest success rates. The first Canadian clinical trial with naltrexone, an opiate antagonist, was conducted to evaluate its safety and usefulness as an adjunctive treatment in the management of alcohol dependence. METHODS: One hundred twenty alcohol-dependent individuals were assessed to receive treatment with 50 mg of naltrexone orally for 12 weeks in an open-label trial. Patients were seen biweekly and received a concurrent psychosocial intervention. Treatment was conducted at multiple sites in Canada. RESULTS: Fifty-four per cent of subjects completed the entire 12 weeks of treatment. During the study, 39% of patients abstained, while of the individuals reporting drinking at baseline, 86% were consuming less alcohol by their final visit. These reductions were accompanied by a significant decrease in craving for alcohol at week 12, as measured by the Obsessive Compulsive Drinking Scale (P<0.01). Naltrexone was well tolerated and no serious adverse events were experienced. CONCLUSIONS: The data lend support to the hypothesis that endogenous opioid activity is involved in the regulation of alcohol intake, and that antagonists of endogenous opioids decrease craving and drinking. Opiate antagonists such as naltrexone are a new strategy in the treatment of alcohol dependence. Naltrexone can be safely given to female and male alcoholics, is acceptable to patients, and plays a role in reducing alcohol consumption and preventing relapse to heavy drinking.