Pediatric Residents' Procedural Competency Requirements: A National Needs Assessment of Program Directors and Chief Residents.

BACKGROUND: There is increased learner competition for a shrinking pool of procedural training opportunities and indications in pediatrics. This study aimed to describe pediatric residency program directors' (PDs) and chief residents' (CRs) perspectives about whether procedural requirements for pediatric residents should be reformed and individualized. METHODS: This was a survey-based, mixed methods study of PDs and CRs affiliated with the Association of Pediatric Program Directors (APPD). We used descriptive statistics to analyze demographics and perspectives, logistic regressions to examine individual and program factors, and thematic analysis for qualitative data. RESULTS: Forty-seven percent (95/203) of PDs and 16% (64/392) of CRs responded, representing APPD membership across program setting, size, and region (average standard mean deviation 0.28). Ninety-one percent of PD respondents considered one or more of the current Accreditation Council for Graduate Medical Education (ACGME) required procedures nonessential; 74% favored individualizing procedural training. CR responses mirrored PD responses. Program size, setting, and access to procedural teams did not significantly associate with likelihood to favor individualization. CONCLUSIONS: The majority of PD and CR respondents believe that current ACGME procedures should be reformed and individualized to future career goals. This change could allow maximization of limited time in residency in this era of decreased opportunity.

Impact of a relationship-centered care communication curriculum on pediatric residents' practice, perspectives, and opportunities to Develop expertise.

OBJECTIVES: To investigate the impacts of a Relationship-Centered Care (RCC) communication curriculum with coaching on pediatric residents 1) self-reported use of RCC strategies and perspectives, and 2) opportunities to develop adaptive expertise. METHODS: Residents (n = 77) completed a 4 h RCC training and shared resultant RCC goals with Coaches (n = 15). Data included resident surveys and reflections immediately post-training, and resident and coach surveys 6-months later. Reported use of RCC strategies were compared over time with paired t-tests. Qualitative data were analyzed using open coding guided by sensitizing principles from the RCC framework and adaptive expertise. RESULTS: Pediatric residents reported significant increases (p < 0.001) in use of 4/9 RCC strategies after 6 months: eliciting all concerns, chunking information, checking for understanding, and teach-back. Resident reflections highlighted shifts in perspective around RCC. Training combined with coaching provided opportunities for residents to develop adaptive expertise through adapting and innovating across settings and contexts. CONCLUSION: Residents had significant increases in reported use of key RCC strategies after a training combined with coaching and demonstrated opportunities to develop adaptive expertise. PRACTICE IMPLICATIONS: Residency programs should include RCC training with an emphasis on the new and challenging strategies and provide opportunities to practice and receive coaching.

Categorical Pediatric Residency Program Curriculum Needs: A Study of Graduating Residents and Residency Program Leadership.

BACKGROUND: Pediatric residency programs must adapt their curriculum to meet evolving patient needs yet face limited resources to implement changes resulting in gaps. We performed a categorical pediatric residency program curriculum needs assessment to inform curriculum development efforts. METHODS: We analyzed data from the 2017 American Academy of Pediatrics Annual Survey of Graduating Residents and pediatric program and associate program director polls conducted at a 2019 pediatric residency program director national meeting. We used conventional content analysis to code and categorize. RESULTS: Participants included 528 (53%) graduating residents representing 88% of programs, 89 program directors, and 177 associate program directors representing at minimum 45% of programs. Participants demonstrated concordance on the top 4 needs-additional clinical experiences, career development, business of medicine, and health systems. Program leaders also identified wellness and resiliency; disparities; diversity, equity, and inclusion; and communication. CONCLUSIONS: This is the first categorical pediatric program general curriculum needs assessment conducted of pediatric leadership and graduating residents in over a decade. While program leadership and resident data were collected 2 years apart, we found concordance on the top 4 categories and consistency with prior national needs assessments with the exception of career development. New curriculum development efforts are underway.

Righting the Autonomy-Supervision Pendulum: Understanding the Impact of Independent Rounds on Medical Students, Residents, and Faculty.

PURPOSE: To explore trainee and faculty perspectives on an independent rounding intervention on general pediatrics wards at 2 institutions. METHOD: In July 2018, the authors introduced independent rounds 1 to 2 times a week at 2 training sites. In this qualitative study, the authors conducted semistructured focus groups with a purposive sample of junior trainees (clerkship medical students and postgraduate year [PGY] 1 residents), senior trainees (PGY-2 and PGY 3-5 residents), and hospital medicine faculty between October 2018 and May 2019. Focus groups were audio-recorded, transcribed verbatim, and analyzed for themes using the constant comparative approach associated with grounded theory. RESULTS: Focus groups included 27 junior trainees, 20 senior trainees, and 18 faculty. Six themes emerged: (1) Independent rounds contributed to all trainees' development; (2) Senior residents described increased motivation to take full ownership of their patients and educational needs of the team; (3) Faculty expressed concerns about decreased opportunities for teaching and feedback; however, all trainees reported unique learning from having faculty both present and absent from rounds; (4) No significant patient safety events were reported; (5) All participants identified communication and patient progression concerns; and (6) A tension emerged between decreased faculty and enhanced trainee career satisfaction. Participants identified solutions to identified barriers to further improve this educational intervention. CONCLUSIONS: As a result of independent rounding, trainees described increased motivation to take ownership of their patients and team. Both rounding experiences contributed to their development as physicians in different ways. Further studies should explore patient and caregiver perspectives and concerns about communication and patient care progression when designing future interventions to promote resident autonomy.

De-escalating Angry Caregivers: A Randomized Controlled Trial of a Novel Communication Curriculum for Pediatric Residents.

OBJECTIVE: Medical providers struggle when communicating with angry patients and their caregivers. Pediatric residents perceive communication competencies as an important priority for learning, yet they lack confidence and desire more training in communicating with angry families. Few curricula exist to support trainees with de-escalation skill development. We developed, implemented, and evaluated the impact of a novel de-escalation curriculum on pediatric resident communication skills. METHODS: We conducted a randomized controlled trial of a 90-minute de-escalation curriculum for pediatric residents from August to September 2016. Trained standardized patient (SP) actors rated residents' communication skills following 2 unique encounters before and after the intervention or control sessions. Residents completed a retrospective pre/post communication skills self-assessment and curriculum evaluation. We used independent and paired t-tests to assess for communication improvements. RESULTS: Eighty-four of 88 (95%) eligible residents participated (43 intervention, 41 control). Residents reported frequent encounters with angry caregivers. At baseline, interns had significantly lower mean SP-rated de-escalation skills than other residents (P = .03). Intervention residents did not improve significantly more than controls on their pre/post change in mean SP-rated de-escalation skills; however, intervention residents improved significantly on their pre/post mean self-assessed de-escalation skills (P ≤ .03). CONCLUSIONS: Despite significant self-assessed improvements, residents' SP-rated de-escalation skills did not improve following a skills-based intervention. Nevertheless, our study illustrates the need for de-escalation curricula focused on strategies and peer discussion, suggests optimal timing of delivery during fall of intern year, and offers an assessment tool for exploration in future studies.

Well-Appearing Newborn With a Vesiculobullous Rash at Birth.

A term, appropriate-for-gestational-age, male infant born via normal spontaneous vaginal delivery presented at birth with a full-body erythematous, vesiculobullous rash. He was well-appearing with normal vital signs and hypoglycemia that quickly resolved. His father had a history of herpes labialis. His mother had an episode of herpes zoster during pregnancy and a prolonged rupture of membranes that was adequately treated. The patient underwent a sepsis workup, including 2 attempted but unsuccessful lumbar punctures, and was started on broad-spectrum antibiotics and acyclovir, given concerns about bacterial or viral infection. The rash evolved over the course of several days. Subsequent workup, with particular attention to his history and presentation, led to his diagnosis.

Increased plasma levels of matrix metalloproteinase-9 in patients with Alzheimer's disease.

Matrix metalloproteinases (MMPs) may play a role in the pathophysiology of Alzheimer's disease (AD). MMP-9 and tissue inhibitors of metalloproteinases (TIMPs) are elevated in postmortem brain tissue of AD patients. MMPs and TIMPs are found in neurons, microglia, vascular endothelial cells and leukocytes. The aim of this study was to determine whether circulating levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 are elevated in the plasma of AD patients. We compared AD patients to age- and gender-matched controls as well as to Parkinson's disease (PD) and amyotrophic lateral sclerosis (ALS) patients. There was constitutive expression of gelatinase A (MMP-2), and gelatinase B (MMP-9), in all the samples as shown by zymographic analysis. Levels of MMP-9 were significantly (P=0.003) elevated in the plasma of AD patients as compared to controls. Plasma levels of MMP-2, TIMP-1 and TIMP-2 were unchanged. There were no significant changes of MMP-2, MMP-9, TIMP-1 and TIMP-2 levels in PD and ALS samples. TIMP-1 and TIMP-2 were significantly correlated with MMP-9 in the AD patients. ApoE genotyping of plasma samples showed that levels of MMP-2, TIMP-1 and TIMP-2 and MMP-9 were not significantly different between the ApoE subgroups. These findings indicate that circulating levels of MMP-9 are increased in AD and may contribute to disease pathology.