Screening for Social Determinants of Health in Pediatric Resident Continuity Clinic.

OBJECTIVE: Describe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET). METHODS: CORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH, including the screen source, timing of screening, process of administering the screen, and personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition. RESULTS: Clinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Barriers to screening included lack of time (63%), resources (50%), and training (46%). CONCLUSIONS: Screening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered.

Milestone Ratings and Supervisory Role Categorizations Swim Together, but Is the Water Muddy?

OBJECTIVE: This single-specialty, multi-institutional study aimed to determine 1) the association between milestone ratings for individual competencies and average milestone ratings (AMRs) and 2) the association between AMRs and recommended supervisory role categorizations made by individual clinical competency committee (CCC) members. METHODS: During the 2015-16 academic year, CCC members at 14 pediatric residencies reported milestone ratings for 21 competencies and recommended supervisory role categories (may not supervise, may supervise in some settings, may supervise in all settings) for residents they reviewed. An exploratory factor analysis of competencies was conducted. The associations among individual competencies, the AMR, and supervisory role categorizations were determined by computing bivariate correlations. The relationship between AMRs and recommended supervisory role categorizations was examined using an ordinal mixed logistic regression model. RESULTS: Of the 155 CCC members, 68 completed both milestone assignments and supervision categorizations for 451 residents. Factor analysis of individual competencies controlling for clustering of residents in raters and sites resulted in a single-factor solution (cumulative variance: 0.75). All individual competencies had large positive correlations with the AMR (correlation coefficient: 0.84-0.93), except for two professionalism competencies (Prof1: 0.63 and Prof4: 0.65). When combined across training year and time points, the AMR and supervisory role categorization had a moderately positive correlation (0.56). CONCLUSIONS: This exploratory study identified a modest correlation between average milestone ratings and supervisory role categorization. Convergence of competencies on a single factor deserves further exploration, with possible rater effects warranting attention.

Key Factors in Clinical Competency Committee Members' Decisions Regarding Residents' Readiness to Serve as Supervisors: A National Study.

PURPOSE: Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role. METHOD: CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis. RESULTS: Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015-2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play. CONCLUSIONS: CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns.

BACKGROUND: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. METHODS: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. RESULTS: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. CONCLUSIONS: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Practice procedures in models of primary care collaboration for children with ADHD.

INTRODUCTION: With nationwide movement toward an integrated medical home, evidence to support, compare, and specify effective models for collaboration between primary care and behavioral health professionals is essential. This study compared 2 models of primary care with behavioral health integration on American Academy of Pediatrics guideline adherence for attention-deficit/hyperactivity disorder (ADHD) assessment and treatment. METHOD: We conducted a retrospective chart review of a random sample of children aged 6-13 years, seen for ADHD services in 2 primary care offices, 1 fully integrated model and 1 co-located service only model, comparing ADHD assessment and treatment practices. We used chi-square analyses and logistic regression modeling to determine differences by type of health care model. RESULTS: Among children with ADHD (n = 149), the integrated care model demonstrated higher rates of guideline adherence, more direct contact with schools, and more frequent behavioral observation during clinical encounters. Families in the integrated practice received more caregiver education on ADHD, behavioral management training, and school advocacy, however, these associations did not remain after accounting for variance associated with onsite engagement with a psychologist. Practices were equivalent on use of medication and psychiatric consultation, although, more families in the integrated practice engaged with a psychologist and attended more frequent medication follow-up appointments than those in the co-located practice. DISCUSSION: This study is among the first to compare different levels of collaborative care on practice procedures. Understanding how we can best integrate between behavioral health and primary care services will optimize outcomes for children and families. (PsycINFO Database Record

Case-Based Workshop for Teaching Child Abuse Prevention to Resident Physicians.

INTRODUCTION: Child abuse is a ubiquitous problem with personal, interpersonal, and social consequences. Risk factors are well established, and preventive strategies have been effective in decreasing abusive parenting behaviors and child maltreatment incident reports. Curriculum tools are needed to incorporate these strategies into training programs so physicians are adequately trained to identify and prevent child maltreatment at the earliest opportunity. METHODS: A literature review established the core content for the curriculum. Resident learning needs were assessed with an online survey sent to graduating residents and teaching faculty. Curriculum objectives were composed to target core content and to address learning needs. Adult learning theories were applied to design interactive, case-based workshops to meet the curriculum objectives. A qualitative assessment tool was distributed to participating residents pre- and postcurriculum. Evaluators were blinded to pre/post status. Follow-up surveys distributed 3 months after the curriculum evaluated for retention of content and application to clinical practice. RESULTS: After workshop participation, residents showed a greater tendency to associate somatic and behavioral complaints with potential toxic stress or abuse and demonstrated understanding of ongoing needs and risks in affected families. On follow-up surveys, most residents self-reported progress toward incorporating discussion of risk factors, stress, and abuse into routine well-child visits. DISCUSSION: Resident physicians who attended the child abuse prevention workshop acquired knowledge and skills relevant to secondary and tertiary child abuse prevention and indicated progress toward primary prevention goals during the subsequent 3 months.

Global Health Education in US Pediatric Residency Programs.

BACKGROUND AND OBJECTIVE: Despite the growing importance of global health (GH) training for pediatric residents, few mechanisms have cataloged GH educational opportunities offered by US pediatric residency programs. We sought to characterize GH education opportunities across pediatric residency programs and identify program characteristics associated with key GH education elements. METHODS: Data on program and GH training characteristics were sought from program directors or their delegates of all US pediatric residency programs during 2013 to 2014. These data were used to compare programs with and without a GH track as well as across small, medium, and large programs. Program characteristics associated with the presence of key educational elements were identified by using bivariate logistic regression. RESULTS: Data were collected from 198 of 199 active US pediatric residency programs (99.5%). Seven percent of pediatric trainees went abroad during 2013 to 2014. Forty-nine programs (24.7%) reported having a GH track, 66.1% had a faculty lead, 58.1% offered international field experiences, and 48.5% offered domestic field experiences. Forty-two percent of programs reported international partnerships across 153 countries. Larger programs, those with lead faculty, GH tracks, or partnerships had significantly increased odds of having each GH educational element, including pretravel preparation. CONCLUSIONS: The number of pediatric residency programs offering GH training opportunities continues to rise. However, smaller programs and those without tracks, lead faculty, or formal partnerships lag behind with organized GH curricula. As GH becomes an integral component of pediatric training, a heightened commitment is needed to ensure consistency of training experiences that encompass best practices in all programs.

Discordance between resident and faculty perceptions of resident autonomy: can self-determination theory help interpret differences and guide strategies for bridging the divide?

PURPOSE: To identify and interpret differences between resident and faculty perceptions of resident autonomy and of faculty support of resident autonomy. METHOD: Parallel questionnaires were sent to pediatric residents and faculty at the University of Rochester Medical Center in 2011. Items addressed self-determination theory (SDT) constructs (autonomy, competence, relatedness) and asked residents and faculty to rate and/or comment on their own and the other group's behaviors. Distributions of responses to 17 parallel Likert scale items were compared by Wilcoxon rank-sum tests. Written comments underwent qualitative content analysis. RESULTS: Respondents included 62/78 residents (79%) and 71/100 faculty (71%). The groups differed significantly on 15 of 17 parallel items but agreed that faculty sometimes provided too much direction. Written comments suggested that SDT constructs were closely interrelated in residency training. Residents expressed frustration that their care plans were changed without explanation. Faculty reported reluctance to give "passive" residents autonomy in patient care unless stakes were low. Many reported granting more independence to residents who displayed motivation and competence. Some described working to overcome residents' passivity by clarifying and reinforcing expectations. CONCLUSIONS: Faculty and residents had discordant perceptions of resident autonomy and of faculty support for resident autonomy. When faculty restrict the independence of "passive" residents whose competence they question, residents may receive fewer opportunities for active learning. Strategies that support autonomy, such as scaffolding, may help residents gain confidence and competence, enhance residents' relatedness to team members and supervisors, and help programs adapt to accreditation requirements to foster residents' growth in independence.

Pediatric resident education in quality improvement (QI): a national survey.

OBJECTIVE: To assess pediatric residents' perceptions of their quality improvement (QI) education and training, including factors that facilitate learning QI and self-efficacy in QI activities. METHODS: A 22-question survey questionnaire was developed with expert-identified key topics and iterative pretesting of questions. Third-year pediatric residents from 45 residency programs recruited from a random sample of 120 programs. Data were analyzed by descriptive statistics, chi-square tests, and qualitative content analysis. RESULTS: Respondents included 331 residents for a response rate of 47%. Demographic characteristics resembled the national profile of pediatric residents. Over 70% of residents reported that their QI training was well organized and met their needs. Three quarters felt ready to use QI methods in practice. Those with QI training before residency were significantly more confident than those without prior QI training. However, fewer than half of respondents used standard QI methods such as PDSA cycles and run charts in projects. Residents identified faculty support, a structured curriculum, hands-on projects, and dedicated project time as key strengths of their QI educational experiences. A strong QI culture was also considered important, and was reported to be present in most programs sampled. CONCLUSIONS: Overall, third-year pediatric residents reported positive QI educational experiences with strong faculty support and sufficient time for QI projects. However, a third of residents thought that the QI curricula in their programs needed improvement, and a quarter lacked self-efficacy in conducting future QI activities. Continuing curricular improvement, including faculty development, is warranted.

Educating residents in behavioral health care and collaboration: comparison of conventional and integrated training models.

PURPOSE: To determine whether former pediatric residents trained using a model of integrated behavioral health (BH) care in their primary care continuity clinics felt more comfortable managing BH care and better prepared to collaborate with BH professionals than did peers from the same residency who trained in clinics with a conventional model of BH care. METHOD: University of Rochester School of Medicine and Dentistry pediatric residents were assigned to one of two continuity clinic sites. At one site, psychology fellows and faculty were integrated into the clinic teams in the mid-1990s. At the other, conventional patterns of consultation and referral continued. In 2004, the authors surveyed 245 alumni (graduated 1989-2003) about their experiences and their comfort with providing BH care and collaborating with BH providers in their current practice. RESULTS: A total of 174 alumni (71%) responded. There were significant differences between graduates who trained in the two models. Those who trained in the integrated model were significantly more likely than others to report that they had consulted or planned treatment with a BH provider during residency and to report that their continuity clinic helped prepare them to collaborate with BH providers. They were somewhat more likely to believe that their overall residency training prepared them to manage BH issues in their current practice. CONCLUSIONS: These findings suggest that an integrated training environment, described in detail in the companion article in this issue, can enhance pediatric resident education in the management of BH problems and collaboration with BH specialists.

Does quality of primary care vary by level of training in pediatric resident continuity practices?

OBJECTIVE: The aim of this study was to compare parental perception of quality of care provided by first- versus third-year pediatric residents who served as their children's primary care providers. METHODS: The Parents' Perception of Primary Care (P3C) survey was administered to all parents who identified a pediatric resident as a primary care provider at 19 Continuity Research Network (CORNET) sites. Parent survey scores were compared between those identifying first-year pediatric residents (PL-1) versus third-year pediatric residents (PL-3) as care providers by using t tests and linear regression modeling, as well as item-specific chi-square analysis and logistic regression. RESULTS: Comparing the responses of the 347 parents who identified a PL-3 resident and the 360 parents who identified a PL-1 resident as their child's primary care provider, those who identified a PL-3 resident rated their childrens overall care higher, with a mean score of 79.2 (95% confidence interval [95% CI] 77.5-80.8) as compared to 75.9 (95% CI 74.4-77.3); P < .05. This disparity was primarily due to differences in the longitudinal continuity domain. Comparisons of the other domains of communication, comprehensiveness, access, contextual knowledge, and coordination showed no statistically significant differences between the 2 groups. Parents rated PL-3 residents as having greater knowledge in behavioral counseling and coordination with schools than PL-1 residents. CONCLUSIONS: Parents rated residents at both training levels very highly for the quality of care provided. PL-3 residents had higher longitudinal continuity scores and were perceived to have greater knowledge about behavioral counseling and coordination of care with schools. Further research will need to elucidate strategies to improve earlier resident acquisition of coordination and behavior management skills.

Spanish-speaking patients perceive high quality care in resident continuity practices: a CORNET study.

Prior research has demonstrated that limited English proficiency in Hispanic patients is associated with adverse health outcomes. The authors sought to compare the perception of primary care in resident practices between Spanish-speaking and English-speaking parents using a previously validated tool, the Parents' Perception of Primary Care. Using survey results from 19 CORNET sites nationwide, they compared mean scores for each primary care domain and the full scale between the groups using Student's t test. Multiple linear regression models compared outcomes controlling for demographic variables. Of the 2122 analyzable surveys, 490 (23%) were completed in Spanish and 1632 (77%) in English. The mean scores for each domain and the total scale were not statistically different between the 2 groups. After adjustment, Spanish-speaking parents rated communication significantly higher. Resident clinics may use systems to provide high quality care to Spanish-speaking patients, which may help other sites improve care.

Pain relief for neonatal circumcision: a follow-up of residency training practices.

OBJECTIVE: To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision. METHODS: All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940). RESULTS: Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%. CONCLUSIONS: The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.