Meaningful Work, Career Fit, and Professional Well-Being of Pediatric Academicians in the United States.

OBJECTIVE: Examine associations between time spent in academic activities perceived as meaningful and professional well-being among academic pediatrics faculty. METHODS: The sample comprised 248 full-time pediatric faculty (76% female, 81% white, non-Hispanic, 41% instructor or assistant professor) across the United States who completed an online survey in November 2019. Survey items included sociodemographic and professional characteristics, professional well-being measures (Stanford Professional Fulfillment Index; Maslach Burnout Inventory; Intention to Leave Academic Medicine), perceived meaningfulness of academic activities and assigned time to those activities. We defined global career fit as total percentage time assigned to professional activities considered meaningful by individuals, and activity-specific career fit as percentage time assigned to each meaningful professional activity. RESULTS: As global career fit scores increased, professional fulfillment increased (r = 0.45, P < .001), whereas burnout (r = -0.29, P < .001) and intention to leave (r = -0.22, P < .001) decreased. Regarding activity-specific career fit, for individuals who considered patient care meaningful, as assigned time to patient care increased, professional fulfillment decreased (r = -0.14, P = .048) and burnout (r = 0.16, P = .02) and intention to leave (r = 0.26, P < .001) increased. There was no significant correlation between assigned time for teaching, research, or advocacy and professional well-being. Faculty were less likely to intend to leave academic medicine as assigned time increased for administrative or leadership activities if considered meaningful (r = -0.24, P = .01). CONCLUSIONS: Time assigned to meaningful work activities may relate to professional well-being of academic pediatrics faculty. More time assigned to patient care, despite being meaningful, was associated with poor self-reported professional well-being. Effort allocation among diverse academic activities needs to be optimized to improve faculty well-being.

What Do Pediatric Subinterns Say About Their Learning and Assessment? A Qualitative Analysis of Individual Learning Plans.

OBJECTIVE: To perform a qualitative content analysis of learning and assessment strategies that pediatric subinterns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning. METHODS: We analyzed ILPs from medical students enrolled in pediatric subinternships at 10 US medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record 3 or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes. RESULTS: Two hundred and four ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in 5 categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students' ability to make and assess progress on their selected learning objectives. CONCLUSIONS: Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessment strategies. The strategies that students identified in this study provide a menu of learning and assessment options for subinterns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment.

Preparedness of Pediatric Subspecialty Fellows to Address Emotional and Mental Health Needs Among Children With Chronic Medical Conditions.

This survey study investigates pediatric subspecialty fellows' attitudes about and perceived competence in addressing emotional and mental health needs of pediatric patients with chronic medical conditions.

Where Do Future Pediatricians Learn Behavioral and Mental Health Skills?

OBJECTIVE: This national study identified the rotations in which pediatric residents received training in the assessment and treatment of behavioral/mental health (B/MH) problems, and examined associations between learning B/MH skills during multiple clinical rotations and resident-reported interest in B/MH issues. METHODS: Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam (62.4% response rate; 1555 eligible respondents). Respondents reported their overall interest in B/MH issues, and specified where they had received training in 7 B.M. assessment skills and 8 treatment skills. Logistic regression models were estimated to identify associations between learning B/MH assessment and treatment skills in multiple clinical rotations and resident-reported B/MH interest, adjusting for respondent characteristics. RESULTS: Respondents reported continuity clinic as the predominant site of B/MH learning, followed by development-behavioral and adolescent rotations. Multisite learning varied across B/MH skills, ranging from 45.1 % (n = 678) for using rating scales to titrate medications to 82.1% (n = 1234) for eliciting parent concerns. 946 (63.2%) reported having overall interest in B/MH issues. Adjusting for respondent characteristics, learning the majority of B/MH skills in >1 rotation was associated with an increased odds of B/MH interest for both assessment and treatment domains (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI] 1.16-1.83 for assessment skills and aOR = 1.36, 95% CI 1.09-1.69 for treatment skills). CONCLUSIONS: The majority of residents report learning B/MH skills in continuity clinic, with substantial variation in the proportion learning these skills in more than one rotation. Teaching B/MH skills during multiple clinical rotations may enhance resident interest in B/MH care delivery for children.

Mental Health Competencies for Pediatric Practice.

Pediatricians have unique opportunities and an increasing sense of responsibility to promote healthy social-emotional development of children and to prevent and address their mental health and substance use conditions. In this report, the American Academy of Pediatrics updates its 2009 policy statement, which proposed competencies for providing mental health care to children in primary care settings and recommended steps toward achieving them. This 2019 policy statement affirms the 2009 statement and expands competencies in response to science and policy that have emerged since: the impact of adverse childhood experiences and social determinants on mental health, trauma-informed practice, and team-based care. Importantly, it also recognizes ways in which the competencies are pertinent to pediatric subspecialty practice. Proposed mental health competencies include foundational communication skills, capacity to incorporate mental health content and tools into health promotion and primary and secondary preventive care, skills in the psychosocial assessment and care of children with mental health conditions, knowledge and skills of evidence-based psychosocial therapy and psychopharmacologic therapy, skills to function as a team member and comanager with mental health specialists, and commitment to embrace mental health practice as integral to pediatric care. Achievement of these competencies will necessarily be incremental, requiring partnership with fellow advocates, system changes, new payment mechanisms, practice enhancements, and decision support for pediatricians in their expanded scope of practice.

Achieving the Pediatric Mental Health Competencies.

Mental health disorders affect 1 in 5 children; however, the majority of affected children do not receive appropriate services, leading to adverse adult outcomes. To meet the needs of children, pediatricians need to take on a larger role in addressing mental health problems. The accompanying policy statement, "Mental Health Competencies for Pediatric Practice," articulates mental health competencies pediatricians could achieve to improve the mental health care of children; yet, the majority of pediatricians do not feel prepared to do so. In this technical report, we summarize current initiatives and resources that exist for trainees and practicing pediatricians across the training continuum. We also identify gaps in mental health clinical experience and training and suggest areas in which education can be strengthened. With this report, we aim to stimulate efforts to address gaps by summarizing educational strategies that have been applied and could be applied to undergraduate medical education, residency and fellowship training, continuing medical education, maintenance of certification, and practice quality improvement activities to achieve the pediatric mental health competencies. In this report, we also articulate the research questions important to the future of pediatric mental health training and practice.

Does Length of Developmental Behavioral Pediatrics Training Matter?

OBJECTIVE: Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. The objective of this study was to compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP with the practice patterns of those who were trained for <4 weeks. METHODS: We used self-reported practices from the American Academy of Pediatrics Periodic Survey 85. Pediatricians were asked whether they never, sometimes, or usually inquired about and screened for, and whether they treated/managed/comanaged attention deficit hyperactivity disorder, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates. RESULTS: Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with attention deficit hyperactivity disorder or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some Diagnostic and Statistical Manual of Mental Disorders criteria and some treatment modalities. CONCLUSIONS: Longer length of training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.

Promoting Early Brain and Child Development: Perceived Barriers and the Utilization of Resources to Address Them.

OBJECTIVE: Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. METHODS: Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted. RESULTS: At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources. CONCLUSIONS: Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

Do On-Site Mental Health Professionals Change Pediatricians' Responses to Children's Mental Health Problems?

OBJECTIVE: To assess the availability of on-site mental health professionals (MHPs) in primary care; to examine practice/pediatrician characteristics associated with on-site MHPs; and to determine whether the presence of on-site MHPs is related to pediatricians' comanaging or more frequently identifying, treating/managing, or referring mental health (MH) problems. METHODS: Analyses included American Academy of Pediatrics (AAP) members who participated in an AAP Periodic Survey in 2013 and who practiced general pediatrics (n = 321). Measures included sociodemographics, practice characteristics, questions about on-site MHPs, comanagement of MH problems, and pediatricians' behaviors in response to 5 prevalent MH problems. Weighted univariate, bivariate, and multivariable analyses were performed. RESULTS: Thirty-five percent reported on-site MHPs. Practice characteristics (medical schools, universities, health maintenance organizations, <100 visits per week, <80% of patients privately insured) and interactions of practice location (urban) with visits and patient insurance were associated with on-site MHPs. There was no overall association between colocation and comanagement, or whether pediatricians usually identified, treated/managed, or referred 5 common child MH problems. Among the subset of pediatricians who reported comanaging, there was an association with comanagement when the on-site MHP was a child psychiatrist, substance abuse counselor, or social worker. CONCLUSIONS: On-site MHPs are more frequent in settings where low-income children are served and where pediatricians train. Pediatricians who comanage MH problems are more likely to do so when the on-site MHP is a child psychiatrist, substance abuse counselor, or social worker. Overall, on-site MHPs were not associated with comanagement or increased likelihood of pediatricians identifying, treating/managing, or referring children with 5 common child MH problems.

A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes.

OBJECTIVE: We investigated ways that patient-centered medical homes (PCMHs) are currently using health information technology (IT) for care coordination and what types of health IT are needed to improve care coordination. MATERIALS AND METHODS: A multi-disciplinary team of researchers conducted semi-structured telephone interviews with 28 participants from 3 PCMHs in the United States. Participants included administrators and clinicians from PCMHs, electronic health record (EHR) and health information exchange (HIE) representatives, and policy makers. RESULTS: Participants identified multiple barriers to care coordination using current health IT tools. We identified five areas in which health IT can improve care coordination in PCMHs: 1) monitoring patient populations, 2) notifying clinicians and other staff when specific patients move across care settings, 3) collaborating around patients, 4) reporting activities, and 5) interoperability. To accomplish these tasks, many participants described using homegrown care coordination systems separate from EHRs. DISCUSSION: The participants in this study have resources, experience, and expertise with using health IT for care coordination, yet they still identified multiple areas for improvement. We hypothesize that focusing health IT development in the five areas we identified can enable more effective care coordination. Key findings from this work are that homegrown systems apart from EHRs are currently used to support care coordination and, also, that reporting tools are key components of care coordination. CONCLUSIONS: New health IT that enables monitoring, notifying, collaborating, reporting, and interoperability would enhance care coordination within PCMHs beyond what current health IT enables.

Maternal literacy and associations between education and the cognitive home environment in low-income families.

OBJECTIVE: To determine whether maternal literacy level accounts for associations between educational level and the cognitive home environment in low-income families. DESIGN: Analysis of 369 mother-infant dyads participating in a long-term study related to early child development. SETTING: Urban public hospital. PARTICIPANTS: Low-income mothers of 6-month-old infants. MAIN EXPOSURE: Maternal literacy level was assessed using the Woodcock-Johnson III/Bateria III Woodcock-Munoz Tests of Achievement, Letter-Word Identification Test. Maternal educational level was assessed by determining the last grade that had been completed by the mother. MAIN OUTCOME MEASURE: The cognitive home environment (provision of learning materials, verbal responsivity, teaching, and shared reading) was assessed using StimQ, an office-based interview measure. RESULTS: In unadjusted analyses, a maternal literacy level of ninth grade or higher was associated with increases in scores for the overall StimQ and each of 4 subscales, whereas a maternal educational level of ninth grade or higher was associated with increases in scores for the overall StimQ and 3 of 4 subscales. In simultaneous multiple linear regression models including both literacy and educational levels, literacy continued to be associated with scores for the overall StimQ (adjusted mean difference, 3.7; 95% confidence interval, 1.7-5.7) and all subscales except teaching, whereas maternal educational level was no longer significantly associated with scores for the StimQ (1.8; 0.5-4.0) or any of its subscales. CONCLUSIONS: Literacy level may be a more specific indicator of risk than educational level in low-income families. Studies of low-income families should include direct measures of literacy. Pediatricians should develop strategies to identify mothers with low literacy levels and promote parenting behaviors to foster cognitive development in these at-risk families.