Cultural Considerations for Patient and Community Education in Global Health: A Qualitative Study in Lesotho.

Background: In global health, international nongovernmental organizations (NGOs) frequently hire, train, and partner with host-country clinicians who manage public outreach and patient care. Purpose and Research Design: We conducted a general interpretivist study of Basotho clinicians hired by NGOs and academic affiliates in Lesotho to identify cultural barriers and facilitators to community and patient education. Data Collection and Analysis: We conducted 13 interviews involving 16 participants (one physician, one nutritionist, 14 nurses). Using an inductive and iterative approach, we analyzed interview transcripts through the lens of social cognitive theory and identified 15 themes. Results: Major findings highlighted: 1) patient and community learners may view Basotho clinicians as authority figures; 2) family and community power dynamics affect healthcare access for vulnerable patient groups; and 3) village leaders may refuse community education when excluded from problem-solving and early planning. Conclusions: Although local clinicians and community members may identify with the same cultural group, clinicians can encounter cultural barriers to patient and community education.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases.

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

An educational intervention to facilitate appropriate subspecialty referrals: a study assessing resident communication skills.

BACKGROUND: Our goal was to improve pediatric residents' advanced communication skills in the setting of referral to address the entrustable professional activity of subspecialty referral identified by the American Board of Pediatrics. To accomplish this aim, we created a referral and consultation curriculum to teach and assess core communication skills in subspecialty referral involving an adolescent with syncope, an anxiety-provoking symptom that is rarely associated with serious pathology. METHODS: We utilized blended multimodal educational interventions to improve resident communication skills in referral of patients. Trainees participated in 1) an interactive online module on syncope focusing on "red-flag" symptoms that would warrant a subspecialty cardiology referral and 2) a 4-h intervention with Standardized Parents (SPs), focusing on the case-based application of communication skills. Communication skills were assessed by two pre- and post- Objective Structured Clinical Examination encounters of patients with syncope, with an SP evaluation using a 20-item checklist. Analysis was performed with Sign test and McNemar's test. Trainees provided feedback on a Critical Incident Questionnaire, which was analyzed qualitatively. RESULTS: Sixty-four residents participated. There was an overall improvement in communication skills based on SP scores (82.7 ± 10.9% to 91.7 ± 5.0%, p < 0.001), and 13/20 items demonstrated significant improvement post-intervention. Residents' improved performance enabled them to address patient/family emotions, explain referral logistics, and clarify concerns to agree on a plan. CONCLUSIONS: By participating in this curriculum, residents' communication skills improved immediately post-intervention. Further research is needed to assess if this intervention improves patient care by providing residents with enduring skills to judiciously manage the referral process.

The Rare Disease Research Scholars Program: A training curriculum for clinical researchers with mixed methods evaluation study.

Rare disease clinician investigators are essential to ensure appropriate diagnosis, care, and treatment for the rapidly growing rare disease population. As these researchers are spread across many specialties, learning the unique skill set for rare disease research (RDR) can be a hurdle and may hinder progress in the field. The need for an RDR focused training program for investigators in many specialties and backgrounds was identified in a needs assessment of trainees in the NIH funded Rare Diseases Clinical Research Network. Based on this information, the Rare Disease Research Scholars Program (RDRSP) was developed. We describe the needs assessment, curriculum creation, scholar recruitment, and outcome evaluation based on four years of programmatic data (2015-2019). This one year-long RDRSP uses a blended approach that includes in-person, web-based, synchronous and asynchronous learning. We evaluated the RDRSP using quantitative and qualitative approaches. Quantitative measures included pre and post questionnaires about knowledge, self-efficacy, and intent to remain in RDR. Data were analyzed using descriptive statistics and a paired t-test. Qualitative semi-structured interviews explored the RDR scholars' perceptions of the RDRSP; thematic analysis examined the textual data. Quantitative pre- and post-measures were statistically significant in the following areas: 1) improved knowledge content in RDR, 2) enhanced self-efficacy in clinical research, and 3) intent to remain in the field of RDR. Qualitative data analysis found the program supported the development of the scholar's research skills as well as 'soft-skills'. By combining training of skills unique to RDR with the more general topics of leadership, mentorship and collaboration among participants in diverse specialties, we created a program that supports the development of the next generation of rare disease clinician investigators and serves as a model for training in other niche research areas.

Leveraging E-Learning and Community Assets to "TEACH" Residents to Address Child Poverty.

OBJECTIVE: To evaluate the effectiveness of a multimodal child poverty curriculum for pediatric residents. METHODS: The Trainee Education in Advocacy and Community Health (TEACH) curriculum trains residents to recognize and address the effects of child poverty, utilizing learning objectives modified from the US Child Poverty Curriculum, new interactive web-based modules, experiential learning, and reflection. This mixed-methods evaluation of the first component, "Epidemiology of Child Poverty," includes nearly 2 years of resident participation. Pre/post knowledge and attitudes regarding child poverty were assessed. Behavior change was evaluated in a subset of participants using an Objective Structured Clinical Examination (OSCE), comparing intervention and control groups of residents. Residents' experience with the curriculum was assessed using qualitative analysis of debrief sessions with faculty. RESULTS: Fifty-two residents completed the curriculum between June 2018 and March 2020. Residents increased in knowledge (P < .001) and confidence (P < .0001) in recognizing and addressing poverty. They also self-reported greater preparedness (P < .001) and effectiveness (P < .001) in addressing social determinants of health. Early data from the OSCE have not shown a statistically significant change in skills compared with a control group. Qualitative themes included an increase in empathy for, understanding of, and responsibility to address the effects of poverty in caring for patients. CONCLUSIONS: The multimodal "Epidemiology of Child Poverty" portion of the TEACH curriculum increased resident knowledge, confidence, and empathy. Given the ubiquitous nature of poverty and the generalizability of the online modules, the TEACH curriculum can be a resource for other residency programs.

Cultural considerations in health care capacity building: A qualitative study in Lesotho.

International non-governmental organisations (NGOs) and academic institutions support health care capacity building to strengthen health systems in low and middle-income countries. We conducted a phenomenological study of foreign and Basotho clinicians who participated in clinical continuing professional development (CPD) in Lesotho. Clinicians included physicians, nurses, and a nutritionist. We sought to understand, through the lens of social cognitive theory, how cultural differences between foreign and Basotho clinicians affected bidirectional clinical education led by NGOs and academic institutions. We also assessed how Basotho clinical educators considered culture when leading NGO-sponsored clinical CPD for Basotho clinicians. After analysing 17 interviews with 24 total participants (four foreign educators, 11 Basotho educators, and nine Basotho learners), using an iterative and inductive approach, we identified 17 themes within the cognitive, environmental, and behavioural domains. Key findings highlighted: (1) cultural tensions between foreign and Basotho culture, including bias against traditional culture; (2) power structures which affected the efficacy of in-service training strategies; (3) perceptions among foreign educators that technical assistance was more effective than direct service delivery at promoting education and sustainability. Educators should map out key relationships and engage local and foreign stakeholders in culturally-focused targeted needs assessments to improve curricular design in capacity building.

Evaluation of Communication and Safety Behaviors During Hospital-Wide Code Response Simulation.

INTRODUCTION: To understand the baseline quality of team communication behaviors at our organization, we implemented institution-wide simulation training and measured the performance of safety behaviors of ad hoc teams in emergent situations. METHODS: Clinicians participated in 2 interprofessional video-recorded simulation scenarios, each followed by debriefing. Using a standardized evaluation instrument, 2 reviewers independently evaluated the presence or absence of desired team safety behaviors, including escalating care, sharing a mental model, establishing leadership, thinking out loud, and identifying roles and responsibilities. We also scored the quality of sharing the mental model, closed-loop communication, and overall team performance on a 7-point scale. Discordant reviews were resolved with scoring by an additional reviewer. RESULTS: A total of 1404 clinicians participated in 398 simulation scenarios, resulting in 257 usable videos. Overall, teams exhibited desired behaviors at the following frequencies: escalating care, 85%; sharing mental models, 66%; verbally establishing leadership, 6%; thinking out loud, 87%; and identifying roles and responsibilities, 27%. Across all reviews, the quality of the graded behaviors (of 7 points) was 2.8 for shared mental models, 3.3 for closed-loop communication, and 3.2 for overall team performance. CONCLUSIONS: In a simulation setting with ad hoc teams, there was variable performance on completing safety behaviors and only a fair quality of graded communication behaviors. These results establish a baseline assessment of communication and teamwork behaviors and will guide future quality improvement interventions.

"TEACH"ing Medical Students to Address Child Poverty: A Multimodal Curriculum.

Literature on the effectiveness of child poverty education in undergraduate medical education is scant. This study adds quantitative and qualitative support for incorporation of a multimodal curriculum to improve student knowledge, confidence, and attitudes toward child poverty.

"Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department.

OBJECTIVES: Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness. METHODS: We used mixed-methods to study pediatric emergency medicine physicians at an academic children's hospital emergency department (ED). Physicians rated patients' illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process. RESULTS: A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0-9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534-0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning. CONCLUSIONS: Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.

Pediatric Hospitalists' Performance and Perceptions of Script Concordance Testing for Self-Assessment.

OBJECTIVES: The cognitive expertise of Pediatric Hospitalists (PH) lies not in standard knowledge but in making decisions under conditions of uncertainty. To maintain expertise, PH should engage in deliberate practice via self-assessments that promote higher-level cognitive processes necessary to address problems with missing or ambiguous information. Higher levels of cognition are purported with Script Concordance Test (SCT) questions compared to Multiple Choice Questions (MCQ). To determine if PH use higher levels of cognition when answering SCT versus MCQ questions and to analyze participants' perceptions of the utility of using SCT self-assessment for deliberate practice in addressing clinical problems encountered in daily practice. METHODS: This is a mixed methods study comparing the cognitive level expressed according to Bloom's Taxonomy by PH answering MCQ versus SCT questions using a "think aloud" (TA) exercise, followed by qualitative analysis of interviews conducted afterward. RESULTS: A significantly greater percentage of comments were coded as higher cognitive processes (apply, analyze, evaluate, and create) for SCT versus MCQ (74% vs 19%) compared with lower order (remember, understand); chi-square P < .00001. Analysis of interviews revealed 6 themes. CONCLUSION: SCT questions elicited higher level cognition essential to clinical reasoning compared to MCQ questions. PH-indicated MCQ questions measure standard knowledge, while SCT questions better measure decision-making under conditions of uncertainty. PH-perceived SCT could be useful for deliberate practice in Pediatric Hospital Medicine decision-making if they could compare their rationale in answering questions with that of experts.

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors.

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

Medical student perspectives on conducting patient experience debrief interviews with hospitalized children and their families.

PURPOSE: To explore how medical students completing a pediatric clerkship viewed the benefits and barriers of debrief interviews with hospitalized patients and families. METHODS: In this study, focus groups were conducted with pediatric clerkship students after completion of a debrief interview. The constant comparative method was used with Mezirow's transformative learning theory as a lens to explore perceptions of the benefits and challenges of performing the interview. RESULTS: Focus groups revealed five benefits and two challenges. The benefits were that the debrief interviews helped students (1) humanize patients and appreciate social and environmental influences on patient health, (2) assess caregiver/patient understanding about care to correct misunderstandings, (3) actively involve caregivers/patients in treatment plan development, (4) engage patients in active expression of questions/concerns, and (5) recognize the value of their own role on the healthcare team. The challenges were that students felt (1) a lack of knowledge to answer caregivers'/patients' questions about diagnoses and (2) discomfort responding to caregiver/patient frustration, anxiety, or sadness. Student feedback on feasibility and implementation led to guidelines for selecting patients and conducting small group discussions after the debrief interviews. CONCLUSIONS: Debrief interviews offer a unique approach for learners to explore patient perspectives during hospitalization through direct patient engagement and dialogue, contributing to professional development, empathy, and potentially more positive patient care experiences.

Entrustable Professional Activities: Correlation of Entrustment Assessments of Pediatric Residents With Concurrent Subcompetency Milestones Ratings.

BACKGROUND: In competency-based medical education, subcompetency milestones represent a theoretical stepwise description for a resident to move from the level of novice to expert. Despite their ubiquitous use in the assessment of residents, they were not designed for that purpose. Because entrustable professional activities (EPAs) require observable behaviors, they could serve as a potential link between clinical observation of residents and competency-based assessment. OBJECTIVE: We hypothesized that global faculty-of-resident entrustment ratings would correlate with concurrent subcompetency milestones-based assessments. METHODS: This prospective study evaluated the correlation between concurrent entrustment assessments and subcompetency milestones ratings. Pediatric residents were assessed in 4 core rotations (pediatric intensive care unit, neonatal intensive care unit, general inpatient, and continuity clinic) at 3 different residency training programs during the 2014-2015 academic year. Subcompetencies were mapped to rotation-specific EPAs, and shared assessments were utilized across the 3 programs. RESULTS: We compared 29 143 pairs of entrustment levels and corresponding subcompetency levels from 630 completed assessments. Pearson correlation coefficients demonstrated statistical significance for all pairs (P < .001). Multivariate linear regression models produced R-squared values that demonstrated strong correlation between mapped EPA levels and corresponding subcompetency milestones ratings (median R 2 = 0.81; interquartile range 0.73-0.83; P < .001). CONCLUSIONS: This study demonstrates a strong association between assessment of EPAs and subcompetency milestones assessment, providing a link between entrustment decisions and assessment of competence. Our data support creating resident assessment tools where multiple subcompetencies can be mapped and assessed by a smaller set of rotation-specific EPAs.

The Patient Experience Debrief Interview: How Conversations With Hospitalized Families Influence Medical Student Learning and Reflection.

PURPOSE: To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning. METHOD: The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from May 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Interrater reliability was examined using kappa. REFLECT scores were analyzed using a chi-square test; essays were analyzed using content analysis. RESULTS: Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the 2 highest levels of reflection, compared with 71% of the intervention group; 2% of the control group attained critical reflection, the highest level, compared with 31% of the intervention group (χ(3, N = 189) = 33.9, P < .001). Seven themes were seen across both groups, 3 focused on physician practice and 4 focused on patients. Patient-centered themes were more common in the intervention group, whereas physician-focused themes were more common in the control group. CONCLUSIONS: Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.

Successful Implementation of a Novel Collaborative Interprofessional Educational Curriculum for Nurses and Residents in a Pediatric Acute Care Setting.

Interprofessional collaboration is vital to maintain a successful healthcare team. We describe the development, implementation, and evaluation of an interprofessional educational curriculum on a large inpatient, acute care pediatric unit. Our objective was to improve attitudes towards collaborative care and collegial relations between staff nurses and pediatric medical residents. Nurses and residents participated in several interventions including a video for the nurses, a video for the residents, a team-building exercise, and three interprofessional clinical simulations. Participants' attitudes toward collaborative care were evaluated by a self-reported questionnaire, adapted from several validated survey instruments, before and after the intervention. Each question was mapped to one of the four domains of interprofessional practice: Teams and Teamwork, Interprofessional Communication, Values and Ethics for Interprofessional Practice, and Roles and Responsibilities. The National Database of Nursing Quality Indicators - Practice Environment Scale (NDNQI-PES) question on collegial nurse and physician relations was also queried to corroborate these findings. There was a statistically significant improvement in the nurses' response to 7/24 (29%) survey questions, of which 4 were within the domain of Teams and Teamwork. There was a statistically significant improvement in the residents' response to 5/24 (21%) questions, of which 3 fell within the domain of Interprofessional Communication. None of the survey questions demonstrated a statistically significant decrease. There was also an improvement on NDNQI-PES scores for the target unit, both during and immediately following the intervention. In conclusion, this educational curriculum involving nurses and residents led to improved participants' attitudes toward interprofessional collaboration.

Tools for Learning About the Referral and Consultation Process for Pediatric Residents.

Management of referral and consultation is an entrustable professional activity for pediatric residents; however, few tools exist to teach these skills. We designed and implemented tools to prompt discussion, feedback, and reflection about the process of referral, notably including the family's perspective.

Problem Representation, Background Evidence, Analysis, Recommendation: An Oral Case Presentation Tool to Promote Diagnostic Reasoning.

Oral case presentations provide an opportunity for trainees to communicate diagnostic reasoning at the bedside. However, few tools exist to enable faculty to provide effective feedback. We developed a tool to assess diagnostic reasoning and communication during oral case presentations.