Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment.

BACKGROUND: Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment. OBJECTIVES: We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale. RESULTS: One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05). CONCLUSIONS: We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Agreement of Program Directors With Clinical Competency Committees for Fellow Entrustment.

OBJECTIVES: Fellowship program directors (FPD) and Clinical Competency Committees (CCCs) both assess fellow performance. We examined the association of entrustment levels determined by the FPD with those of the CCC for 6 common pediatric subspecialty entrustable professional activities (EPAs), hypothesizing there would be strong correlation and minimal bias between these raters. METHODS: The FPDs and CCCs separately assigned a level of supervision to each of their fellows for 6 common pediatric subspecialty EPAs. For each EPA, we determined the correlation between FPD and CCC assessments and calculated bias as CCC minus FPD values for when the FPD was or was not a member of the CCC. In addition, we examined the effect of program size, FPD understanding of EPAs, and subspecialty on the correlations. Data were obtained in fall 2014 and spring 2015. RESULTS: A total of 1040 fellows were assessed in the fall and 1048 in the spring. In both periods and for each EPA, there was a strong correlation between FPD and CCC supervision levels (P < .001). The correlation was somewhat lower when the FPD was not a CCC member (P < .001). Overall bias in both periods was small. CONCLUSIONS: The correlation between FPD and CCC assignment of EPA supervision levels is strong. Although slightly weaker when the FPD is not a CCC member, bias is small, so this is likely unimportant in determining fellow entrustment level. The similar performance ratings of FPDs and CCCs support the validity argument for EPAs as competency-based assessment tools.

Integrated, Family-based, Partial Hospital Treatment for Complex Pediatric Illness.

This paper describes a unique treatment program for complex pediatric illness. The Hasbro Children's Partial Hospital Program uses a family systems orientation, integrated care, and a partial hospital setting to treat children with a wide range of pediatric illnesses that have failed outpatient and inpatient treatments. We have treated more than 2000 children with at least 80 different ICD-9 diagnoses. The multidisciplinary treatment team functions as a meta-family for children and their families who present with illness and family beliefs that impede successful outcomes with standard care. The three features: family systems orientation, integrated care, and partial hospital setting, hopefully interact to create an environment that helps families expand and modify their explanatory models regarding participating in effective medical care. The goal of treatment is for both children and their parents to feel empowered to take control of the illness. Parents completing standardized measures at intake describe their children and families as experiencing significant emotional distress, low levels of general family functioning, and poor quality of life. Although the children are described as having distinct behavioral differences, the families are described as responding to the experience of a seriously ill child in similar ways. A treatment program that addresses the noncategorical aspects of how families respond to illness while addressing the specific diseases of the children can allow children and their families to respond favorably to treatment.

En este artículo se describe un programa de tratamiento único para las enfermedades pediátricas complejas. El programa hospitalario parcial de Hasbro Children's Hospital utiliza una orientación de sistemas familiares, atención integrada y un formato de hospital parcial para tratar a niños con una amplia variedad de enfermedades pediátricas a quienes los tratamientos ambulatorios y con internación no les han dado resultado. Hemos tratado a más de 2000 niños con, por lo menos, 80 diagnósticos diferentes de ICD-9. El equipo de tratamiento multidiscplinario funciona como una metafamilia para los niños y sus familiares que presentan una enfermedad y creencias familiares que impiden resultados favorables con la atención convencional. Las tres características: orientación de sistemas familiares, atención integrada y formato de hospital parcial interactuarían para crear un entorno que ayude a las familias a ampliar y modificar sus modelos explicativos con respecto a participar en una atención médica eficaz. El objetivo del tratamiento es que tanto los niños como sus padres se sientan facultados para tomar las riendas de la enfermedad. Los padres que se someten a evaluaciones estandarizadas en el ingreso explican que sus hijos y familias sufren distrés emocional considerable, niveles bajos de funcionamiento familiar general y una mala calidad de vida. Si bien se describe a los niños como personas con diferencias conductuales definidas, las familias se describen como personas que responden a la experiencia de un niño gravemente enfermo de formas similares. Un programa de tratamiento que aborde los aspectos no categóricos de las formas en las que las familias responden a la enfermedad y que, al mismo tiempo, aborde las enfermedades específicas de los niños puede permitir a los niños y a sus familias responder favorablemente al tratamiento.

Epigenetics and child abuse: Modern-day Darwinism--The miraculous ability of the human genome to adapt, and then adapt again.

It has long been recognized that early adversity can have life-long consequences, and the extent to which this is true is gaining increasing attention. A growing body of literature implicates Adverse Childhood Experiences, including physical, sexual, and emotional abuse, in a broad range of negative health consequences including adult psychopathology, cardiovascular, and immune disease. Increasing evidence from animal, clinical, and epidemiological studies highlight the critical role of epigenetic programing, such as DNA methylation and histone modification, in altering gene expression, brain structure and function, and ultimately life-course trajectories. This review outlines our developing insight into the interplay between our human biology and our changing environment, and explores the growing evidence base for how interventions may prevent and ameliorate damage inflicted by toxic stress in early life.

Literacy promotion: an essential component of primary care pediatric practice.

Reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by (1) advising all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills; (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word; (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children; (4) using a robust spectrum of options to support and promote these efforts; and (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences. The AAP supports federal and state funding for children's books to be provided at pediatric health supervision visits to children at high risk living at or near the poverty threshold and the integration of literacy promotion, an essential component of pediatric primary care, into pediatric resident education. This policy statement is supported by the AAP technical report "School Readiness" and supports the AAP policy statement "Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health."

Resident education in developmental behavioral pediatrics: the impact of the 80-hour work week.

OBJECTIVE: This study assessed the structure of pediatric resident developmental behavioral pediatrics (DBP) rotations in the context of the Accreditation Council for Graduate Medical Education duty hour mandates. METHODS: : We distributed an online survey addressing rotation structure, call schedule, and impact of the duty hour policy to resident DBP rotation directors in 114 of 204 pediatric residency programs in the United States and Canada and received responses from 81 programs (71% response rate). RESULTS: Seventy-five percent of respondents reported an average of 16% reduction in their DBP rotation after implementation of the Duty Hours rule in 2003. More programs having overnight calls during the rotation reported decreases versus those without overnight calls (91% vs 52%, p < .001). CONCLUSIONS: Decreases in exposure to DBP, a result of duty hour mandates, may be negatively impacting benefits of mandatory DBP rotations. Attention may need to be given to the consequences for resident education in DBP.

Longitudinal study of maternal report of sleep problems in children with prenatal exposure to cocaine and other drugs.

Sleep data were collected by maternal report in a prospective longitudinal follow up of cocaine-exposed and unexposed children. There were 139 participants: 23 with no prenatal drug exposure, 55 exposed to cocaine alone or in combination with other drugs, and 61 exposed to drugs other than cocaine. Characteristics differed between exposure groups including birth size, caretaker changes, maternal socioeconomic status, and postnatal drug use. Compared to those with no drug exposure, children with prenatal drug exposure other than cocaine experienced greater sleep problems (p = .026). Prenatal nicotine exposure was a unique predictor of sleep problems (p = .048). Early sleep problems predicted later sleep problems (all ps < .01). Together, these preliminary findings suggest possible neurotoxic sleep effects that persist over time. Larger studies, however, need to be conducted that better control for potential postnatal confounding factors.

School readiness.

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to be ready for all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for community-based programs, rather than an exclusion criterion at the beginning of the formal educational experience. Our new knowledge of early brain and child development has revealed that modifiable factors in a child's early experience can greatly affect that child's learning trajectory. Many US children enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification of and attention to child and family needs. Pediatricians have a role in promoting school readiness for all children, beginning at birth, through their practices and advocacy. The American Academy of Pediatrics affords pediatricians many opportunities to promote the physical, social-emotional, and educational health of young children, with other advocacy groups. This technical report supports American Academy of Pediatrics policy statements "Quality Early Education and Child Care From Birth to Kindergarten" and "The Inappropriate Use of School 'Readiness' Tests."