From helplessness to transformation: An analysis of clinician narratives about the social determinants of health and their implications for training and practice.

BACKGROUND: Medical curricula are attempting to prepare trainees to address the social determinants of health, however the life circumstances of patients are often beyond physician control. Little is known about how physicians cope with this dilemma; we sought to examine their perspectives when faced with this challenge to help better prepare trainees for practice. METHODS: We undertook a critical analysis of physician narratives from January 2018 to June 2020. In total, 268 physician-written narrative social determinant of health pieces from four high impact medical journals were screened and 47 met the inclusion criteria and were analysed. RESULTS: We identified four storylines that described the physician experience and strategies for coping with the social determinants of health. While Helplessness stories described authors' experiences of emotional distress when unable to support their patients, the other story types described ways they could make a difference. In Shortcoming and Transformation stories, the realisations about shortcomings led to transformation. In Doctor-patient relationship stories, authors described its importance in theirs and patients' lives, and in System advocacy stories, they described the need for greater advocacy to help change broken systems. CONCLUSIONS: Current approaches to teaching the social determinants of health often focus on the role of physicians in recognising and altering social circumstances. However, the realities of practice do not easily allow physicians to do so and, for some, may lead to distress and burnout. There are other ways to cope and make a difference by improving ourselves, investing in getting to know our patients, and advocating. These results can help better support trainees and physicians for the realities of practice.

Severe Generalized Bullous Fixed Drug Eruption Treated with Cyclosporine: A Case Report and Literature Review.

Generalized bullous fixed drug eruptions (GBFDEs) are rare in the paediatric population. We present the case of a 7-year-old girl with GBFDE believed to be secondary to oral ibuprofen, who experienced rapid resolution of lesions and cessation of blistering with a 3-week course of oral cyclosporine. To the best of our knowledge, this is the first report of a paediatric case of GBFDE treated with cyclosporine. In our report, we review published cases of GBFDE in children, and all adult cases managed with cyclosporine.

A Blended Model of Case-Based Learning in a Paediatric Clerkship Program.

Education during the clinical clerkship years requires active learning. Students cannot be bystanders, but rather they must discover, apply, and integrate new information in a clinical context. We present a novel model of case-based learning that encourages active learning, focusing on problem-solving skills for the clinical environment.

Complex care for kids Ontario: protocol for a mixed-methods randomised controlled trial of a population-level care coordination initiative for children with medical complexity.

INTRODUCTION: Technological and medical advances have led to a growing population of children with medical complexity (CMC) defined by substantial medical needs, healthcare utilisation and morbidity. These children are at a high risk of missed, fragmented and/or inappropriate care, and families bear extraordinary financial burden and stress. While small in number (<1% of children), this group uses ~1/3 of all child healthcare resources, and need coordinated care to optimise their health. Complex care for kids Ontario (CCKO) brings researchers, families and healthcare providers together to develop, implement and evaluate a population-level roll-out of care for CMC in Ontario, Canada through a randomised controlled trial (RCT) design. The intervention includes dedicated key workers and the utilisation of coordinated shared care plans. METHODS AND ANALYSIS: Our primary objective is to evaluate the CCKO intervention using a randomised waitlist control design. The waitlist approach involves rolling out an intervention over time, whereby all participants are randomised into two groups (A and B) to receive the intervention at different time points determined at random. Baseline measurements are collected at month 0, and groups A and B are compared at months 6 and 12. The primary outcome is the family-prioritized Family Experiences with Coordination of Care (FECC) survey at 12 months. The FECC will be compared between groups using an analysis of covariance with the corresponding baseline score as the covariate. Secondary outcomes include reports of child and parent health outcomes, health system utilisation and process outcomes. ETHICS AND DISSEMINATION: Research ethics approval has been obtained for this multicentre RCT. This trial will assess the effect of a large population-level complex care intervention to determine whether dedicated key workers and coordinated care plans have an impact on improving service delivery and quality of life for CMC and their families. TRIAL REGISTRATION NUMBER: NCT02928757.

Factors Associated With Discharge Home After Transfer to a Pediatric Emergency Department.

OBJECTIVES: The transfer of children from community emergency departments (EDs) to tertiary care pediatric EDs for investigations, interventions, or a second opinion is common. In order to improve health care system efficiency, we must have a better understanding of this population and identify areas for education and capacity building. METHODS: We conducted a retrospective chart review of all patients (aged 0-17 years) who were transferred from community ED to a pediatric ED from November 2013 to November 2014. The primary outcome was the frequency of referred patients who were discharged home from the pediatric ED. RESULTS: Two hundred four patients were transferred from community EDs in the study period. One hundred thirteen children (55.4%) were discharged home from the pediatric ED. Presence of inpatient pediatric services (P = 0.04) at the referral hospital and a respiratory diagnosis (P = 0.03) were independently associated with admission to the children's hospital. In addition, 74 patients (36.5%) had no critically abnormal vital signs at the referral hospital and did not require any special tests, interventions, consultations, or admission to the children's hospital. Younger age (P = 0.03), lack of inpatient pediatric services (P = 0.04), and a diagnosis change (P = 0.03) were independently associated with this outcome. CONCLUSIONS: More than half of patients transferred to the pediatric tertiary care ED did not require admission, and more than one third did not require special tests, interventions, consults, or admission. Many of these patients were likely transferred for a second opinion from a pediatric emergency medicine specialist. Education and real-time videoconferencing consultations using telemedicine may help to reduce the frequency of transfers for a second opinion and contribute to cost savings over the long term.