Etiologies and early diagnosis of short stature and growth failure in children and adolescents.

Accurate measurement of height and weight using standardized techniques is a fundamental component of pediatric medical visits. Calculation of height velocity over time enables comparison with standardized growth charts to identify potential deviations from normal. Growth deviations may be expressed as SD from the normal population mean for children of comparable age and sex; children with heights >2 SD below the mean are generally classified as short stature. In a child with suspected impaired growth, a detailed evaluation should be conducted to identify the cause. Such an evaluation may include a combination of personal, family, and social history; physical examination; general and perhaps specialized laboratory evaluations; radiologic examinations; genetic testing; and consultation with a pediatric subspecialist, such as a pediatric endocrinologist. Variants of normal growth include familial short stature, constitutional delay of growth and puberty, and small for gestational age with catch-up growth. Pathological causes of abnormal growth include many systemic diseases and their treatments, growth hormone deficiency, and a series of genetic syndromes, including Noonan syndrome and Turner syndrome. Children with short stature in whom no specific cause is identified may be diagnosed with idiopathic short stature. Early identification of abnormal growth patterns and prompt referral to specialist care offer children with growth failure and/or short stature the greatest chance for appropriate diagnosis, treatment, and improved clinical outcomes.

Responding to a changing nation: are faculty prepared for cross-cultural conversations and care?

BACKGROUND AND OBJECTIVES: The United States is becoming increasingly diverse. Health disparities continue with little improvement despite national policies and standards. Medical institutions are modifying their curricula; however, little is known about faculty attitudes and comfort in addressing cultural issues. The purpose of this study was to determine faculty attitudes, self-perceived levels of comfort and skill, and future knowledge needs pertaining to cultural competence. METHODS: A survey was administered to all clinical faculty at the University of Virginia School of Medicine. Survey questions addressed faculty attitudes and self-perceived levels of comfort and skill in dealing with cultural issues, as well as perceived need and interest in future cultural competence training. RESULTS: When considering each phase of education (medical school, residency, continuing medical education [CME]), fewer than 25% of the respondents reported receiving formal instruction in cultural competency in any given phase, although 93% felt that cultural competency training was important. Fifty-eight percent felt "very comfortable" caring for diverse patients, although this dropped to 30% when specifying limited English proficiency. The situation in which the highest percentage of respondents felt "not particularly comfortable" or "not at all comfortable" was breaking bad news to a patient's family first if this was more culturally appropriate (47%). Respondents felt most skilled in working with medical interpreters, apologizing for cross-cultural misunderstandings, and eliciting the patients' perspectives about their health and illness. Respondents felt the least skilled providing culturally sensitive end-of-life care and dealing with cross-cultural conflicts. CONCLUSIONS: Clinical faculty have received limited instruction on cultural competency, and the reported levels of comfort and skill in many challenging areas of multicultural health leave much room for improvement. Until faculty become more comfortable and are able to model and teach these behaviors to learners, positive responses to national policies in culturally competent care are likely to be limited.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

A review of the Journal of Pediatrics: the first 75 years.

OBJECTIVE: To assess changes in the format and content of articles published in The Journal of Pediatrics to aid in understanding the current state of pediatric research and to anticipate what to expect in the coming years. STUDY DESIGN: We conducted a retrospective review of case reports, research articles, and review articles published in volume 150 of The Journal. We noted components of study authorship, content, and design and compared these data with those in earlier volumes. RESULTS: The numbers of authors and grants per article and the proportion of studies with international authorship have all increased. Print circulation has dropped, but The Journal is now available in electronic format. Research topics shifted, with fewer articles devoted to infectious disease and general pediatrics. An increase in articles about endocrinology reflects a surge of interest in pediatric obesity. Most articles contain original research, reporting analyses from observational studies with few clinical trials. CONCLUSIONS: Recent trends suggest that readers of The Journal should expect more research articles with observational designs and increasing international authorship. The Journal's electronic presence will likely increase and provide greater readership globally.

Statistical literacy for readers of Pediatrics: a moving target.

OBJECTIVE: Pediatric residents are expected to study research design and statistical methods to enable them to critically appraise the pediatric literature and apply the findings to patient care. However, it is not clear how best to teach these skills or even which statistical concepts are most important. An earlier study demonstrated that the statistical complexity of articles published in Pediatrics increased from 1952 to 1982. The goals of our study were to assess whether this trend has continued and to determine the statistical measures and procedures most commonly encountered in Pediatrics. METHODS: We reviewed the print research articles published in Pediatrics, volume 115, 2005, and recorded the statistical measures and procedures reported in each article to determine how many articles used statistics or statistical procedures and what statistical procedures were encountered most commonly. RESULTS: The proportion of articles that used any inferential statistics increased from 48% in 1982 to 89% in 2005. The mean number of inferential procedures per article increased from 2.5 in 1982 to 3.9 in 2005. The most commonly encountered statistical procedures or measures were descriptive statistics, tests of proportions, measures of risk, logistic regression, t tests, nonparametric tests, analysis of variance, multiple linear regression, sample size and power calculation, and tests of correlation. However, a reader who is familiar with only these concepts can understand the analyses used in only 47% of articles. CONCLUSIONS: Our results confirm a trend toward the use of new and increasingly complex statistical techniques in Pediatrics. Educational efforts might most profitably focus on the principles underlying statistical analysis rather than on specific statistical tests. Authors, reviewers, and journal editors have a greater responsibility for ensuring that statistical procedures are used appropriately, as it may be increasingly unrealistic to expect readers to fully understand the statistical analyses used in journal articles.

Predicting rural practice using different definitions to classify medical school applicants as having a rural upbringing.

PURPOSE: This study determines the relationship between a medical school applicant's rural background and the likelihood of rural practice using different definitions of rural background. METHODS: Cohort study of 599 physicians who entered the University of Virginia School of Medicine in 1990-1995 and graduated in 1994-1999. The "rurality" of the applicants' backgrounds was assessed by coding applicants' high school, college, and permanent addresses using 4 definitions of rural. In addition, most physicians responded to a survey question "Did you grow up in a rural area?" The same 4 definitions of rural were used to assess the rurality of practice locations. Logistic regression models were used to predict the simultaneous effect of different definitions of rural background, gender, and applicants' career preference at matriculation on the probability of practicing in rural areas. FINDINGS: In univariate analyses, the high school, college, and permanent addresses were all predictive of rural practice using 1 or more definitions of rural. In the multivariate analysis, only the "grew up rural" self-description was predictive of rural practice location using 3 of the definitions of rural. In a secondary analysis, the grew up rural self-description and applicants' career preferences at matriculation were predictors of rural practice. CONCLUSIONS: Readily available addresses were predictive of rural practice. In a multivariate analysis, physicians' self-description about having grown up in a rural area was the best predictor of rural practice. Recruiting more applicants who match this definition of rural background should increase the number of rural physicians.

Case-control confusion.

OBJECTIVE: Critical analysis of journal articles by using principles of evidence-based medicine is important for clinicians applying research results in their practice and is a valuable component of pediatric residency training. Appraisal of an article's methodological rigor is often tailored to a particular type of study design, so that misclassification of study design can confuse the appraisal. The goal of this study was to determine how often pediatric research articles that are self-declared as case-control studies conform to a standard definition for this study design. METHODS: A Medline search identified articles published in two pediatric journals from January 1996 through August 2004 with the phrase "case-control study" in the title or abstract. Articles that were self-declared as case-control studies were analyzed to determine whether they satisfied a standard definition of a case-control study. RESULTS: Of the 91 purported case-control studies, only 68 (75%) met the standard definition for at least the most important analysis. The remaining 23 articles could be classified as cross-sectional studies (N = 16) or prospective cohort studies (N = 7). CONCLUSIONS: Ambiguity in the definition of a case-control study can cause confusion in the critical appraisal of published clinical research.

Effect of a second-year primary care preceptorship on medical students' career plans.

BACKGROUND: Preceptorships with community physicians have been incorporated into medical curricula to foster interest in generalist careers. An evaluation of our preceptorship program was undertaken to determine this influence. METHODS: Students were asked about career interests before and after a second-year community preceptorship. When graduating, those students entering primary-care residencies were surveyed to validate whether they planned to become generalist or specialist. Associations between career choice at graduation and career interest before and after the preceptorship were examined. RESULTS: Of 73 students who maintained a generalist career plan after the community preceptorship, 57 (78%) continued with the same at graduation. After the preceptorship, 70 students reported a change in career interest toward generalism, compared with 9 who reported an interest in specialism. A significant relationship was found between career interest change and career choice at graduation. CONCLUSION: Our community preceptorship had a modest impact in stimulating students to consider generalist careers.

Maladies in musicians.

Certain medical ailments occur with increased frequency among musicians and can affect musicians of all ages and ability. These maladies range in severity from incidental, asymptomatic findings among casual a nd occasional players to serious injuries that significantly disable professional musicians from practicing or performing. The most prevalent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward position. Other common problems include dermatologic irritation, peripheral neuropathies, focal dystonias, and otolaryngologic disorders. This review organizes the musical maladies according to section of the orchestra with further subclassification by pathologic process. By becoming familiar with the disorders associated with specific instruments, physicians will be better able to make the correct diagnosis in musicians with medical complaints.

Can medical school admission committee members predict which applicants will choose primary care careers?

PURPOSE: To determine the accuracy of admission committee members' predictions regarding which applicants are likely to become generalists, and to determine which applicant characteristics are used and should be used in making these predictions. METHOD: Thirteen characteristics of each applicant who entered medical school in 1990-1993 and graduated in 1994-1997 were obtained from their applications. Committee members reviewed these characteristics and assigned a probability of each applicant's choosing a generalist career. Just before their graduation, the students were surveyed to ascertain their career plans. The relationships between the characteristics and career predictions were analyzed using regression models. A secondary analysis examined the relationship between the students' stated career preferences at matriculation and career plans at graduation. RESULTS: The accuracy of the committee members' predictions was low. Predictions of generalist careers were significantly related to seven applicant characteristics: rural legal residence, gender (women), lower science grades, lower MCAT science scores, lower levels of parents' education, no reported research activity, and higher levels of community service. In contrast, the students' actual generalist career plans at graduation were significantly related only to gender (women) and higher levels of community service. In the secondary analysis, applicants' stated career preferences at matriculation were the strongest predictor of their having generalist career plans at graduation. CONCLUSIONS: Admission committee members often made inaccurate predictions about applicants' career plans. This may be because they based their judgments on applicants' characteristics that were not significantly related to the students' career plans at graduation.