A structured genetics rotation for pediatric residents: an important educational opportunity.

PURPOSE: As the integral role of genetics in health and disease becomes increasingly understood, pediatricians must incorporate genetic principles into their care of patients. Structured exposure to genetics during residency may better equip future pediatricians to meet this goal. METHODS: Pediatric interns in the Johns Hopkins pediatric residency program have the option to spend one week immersed in clinical genetics by attending outpatient clinics and seeing inpatient consults. A pretest assessing clinical genetics knowledge is given before the rotation and compared with an identical post-test. Interns have a "scavenger hunt" to introduce genetic resources useful to pediatricians and complete a logbook of patient experiences. An evaluation is completed at the end of the rotation. RESULTS: Since the selective started in July 2016, 50 interns have participated. Average pretest score was 2.5/5 compared with a post-test score of 4.3/5, p < 0.0001. Interns saw on average ten patients and four different diagnoses. Overall evaluation was 4.4 on a 5-point scale, 5 being "excellent." CONCLUSION: This experience suggests that a structured rotation in genetics provides pediatric interns with an opportunity to learn basic clinical genetics knowledge and skills and see patients whom they may otherwise not encounter during residency.

Two Novel Urban Health Primary Care Residency Tracks That Focus On Community-Level Structural Vulnerabilities.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents' understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations.

Development and Implementation of a School-Wide Institute for Excellence in Education to Enable Educational Scholarship by Medical School Faculty.

PROBLEM: Educational scholarship is an important component for faculty at Academic Medical Centers, especially those with single-track promotion systems. Yet, faculty may lack the skills and mentorship needed to successfully complete projects. In addition, many educators feel undervalued. INTERVENTION: To reinvigorate our school's educational mission, the Institute for Excellence in Education (IEE) was created. Here we focus on one of the IEE's strategic goals, that of inspiring and supporting educational research, scholarship, and innovation. CONTEXT: Using the 6-step curriculum development process as a framework, we describe the development and outcomes of IEE programs aimed at enabling educational scholarship at the Johns Hopkins University School of Medicine. OUTCOME: Four significant programs that focused on educational scholarship were developed and implemented: (a) an annual conference, (b) a Faculty Education Scholars' Program, (c) "Shark Tank" small-grant program, and (d) Residency Redesign Challenge grants. A diverse group of primarily junior faculty engaged in these programs with strong mentorship, successfully completing and disseminating projects. Faculty members have been able to clarify their personal goals and develop a greater sense of self-efficacy for their desired paths in teaching and educational research. LESSONS LEARNED: Faculty require programs and resources for educational scholarship and career development, focused on skills building in methodology, assessment, and statistical analysis. Mentoring and the time to work on projects are critical. Key to the IEE's success in maintaining and building programs has been ongoing needs assessment of faculty and learners and a strong partnership with our school's fund-raising staff. The IEE will next try to expand opportunities by adding additional mentoring capacity and further devilment of our small-grants programs.

Lawyer mothers: infant-feeding intentions and behavior.

OBJECTIVES: Maternal employment postpartum can have a powerful influence over infant-feeding behaviors. The objective of this cross-sectional online survey was to explore the infant-feeding intentions and behaviors of a convenience sample of lawyer mothers. We compared our findings with those for physician mothers. METHODS: Lawyers participated in an anonymous online survey. To eliminate the influence of multiple births, only study subjects with one child were reviewed for inclusion in this analysis. We used SPSS for calculation of descriptive statistics, the Mann-Whitney test for comparisons, and the Spearman rank correlation test for testing correlations. RESULTS: All mothers (29 lawyers and 47 physicians) included in the final analysis reported an intention to breast-feed, with 55% of lawyers wanting to breast-feed for at least 12 months. Physicians' breast-feeding rates were 98% at birth, 83% at 6 months, and 51% at 12 months. Lawyers' breast-feeding rates were 100% at birth, 55% at 6 months, and 17% at 12 months. Their duration of breast-feeding correlated with the support level at work and the sufficiency of time and availability of appropriate places at work to express milk. CONCLUSIONS: This study did not detect statistically significant differences in infant-feeding intentions and behaviors of lawyer mothers when compared with physician mothers. Although the majority of lawyer mothers intended to breast-feed for at least 12 months, only a minority achieved that goal. Our findings support the development of workplace strategies and programs to promote breast-feeding duration among lawyers returning to work after childbirth.

Defining the transition from new to normal: a qualitative investigation of the clinical change process.

Background: Understanding how and when a new evidence-based clinical intervention becomes standard practice is crucial to ensure that healthcare is delivered in alignment with the most up-to-date knowledge. However, rigorous methods are needed to determine when a new clinical practice becomes normalized to the standard of care. To address this gap, this study qualitatively explores how, when, and why a clinical practice change becomes normalized within healthcare organizations. Methods: We used purposive sampling to recruit clinical leaders who worked in implementation science across diverse health contexts. Enrolled participants completed semi-structured interviews. Qualitative data analysis was guided by a modified version of the Normalization Process Theory (NPT) framework to identify salient themes. Identified normalization strategies were mapped to the Expert Recommendations for Implementation Change (ERIC) project. Results: A total of 17 individuals were interviewed. Participants described four key signals for identifying when a novel clinical practice becomes the new normal: 1) integration into existing workflows; 2) scaling across the entire organizational unit; 3) staff buy-in and ownership; and 4) sustainment without ongoing monitoring. Participants identified salient strategies to normalize new clinical interventions: 1) taking a patient approach; 2) gaining staff buy-in and ownership; and 3) conducting ongoing measurement of progress towards normalization. Conclusions: The results offer valuable insight into the indicators that signify when a novel clinical practice becomes normalized, and the strategies employed to facilitate this transition. These findings can inform future research to develop instruments that implementation leaders can use to systematically measure the clinical change process.

Meaningful Work, Career Fit, and Professional Well-Being of Pediatric Academicians in the United States.

OBJECTIVE: Examine associations between time spent in academic activities perceived as meaningful and professional well-being among academic pediatrics faculty. METHODS: The sample comprised 248 full-time pediatric faculty (76% female, 81% white, non-Hispanic, 41% instructor or assistant professor) across the United States who completed an online survey in November 2019. Survey items included sociodemographic and professional characteristics, professional well-being measures (Stanford Professional Fulfillment Index; Maslach Burnout Inventory; Intention to Leave Academic Medicine), perceived meaningfulness of academic activities and assigned time to those activities. We defined global career fit as total percentage time assigned to professional activities considered meaningful by individuals, and activity-specific career fit as percentage time assigned to each meaningful professional activity. RESULTS: As global career fit scores increased, professional fulfillment increased (r = 0.45, P < .001), whereas burnout (r = -0.29, P < .001) and intention to leave (r = -0.22, P < .001) decreased. Regarding activity-specific career fit, for individuals who considered patient care meaningful, as assigned time to patient care increased, professional fulfillment decreased (r = -0.14, P = .048) and burnout (r = 0.16, P = .02) and intention to leave (r = 0.26, P < .001) increased. There was no significant correlation between assigned time for teaching, research, or advocacy and professional well-being. Faculty were less likely to intend to leave academic medicine as assigned time increased for administrative or leadership activities if considered meaningful (r = -0.24, P = .01). CONCLUSIONS: Time assigned to meaningful work activities may relate to professional well-being of academic pediatrics faculty. More time assigned to patient care, despite being meaningful, was associated with poor self-reported professional well-being. Effort allocation among diverse academic activities needs to be optimized to improve faculty well-being.

Addressing adverse social determinants of health in pediatric primary care: Study protocol for a hybrid type 2 effectiveness-implementation randomized controlled trial in two national pediatric practice-based research networks.

BACKGROUND: Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices. METHODS: We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases. DISCUSSION: Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.

Work-place predictors of duration of breastfeeding among female physicians.

OBJECTIVE: To identify work-related predictors of breastfeeding duration among female physicians. STUDY DESIGN: Data on 238 children were obtained from 50 female physicians, whose main affiliation was with Johns Hopkins University (Baltimore, MD), and 80 female physicians, whose main affiliation was with the University of Florida (Gainesville, FL). We used a mixed linear model to determine which variables were significant predictors of breastfeeding duration when controlling for maternal demographics and taking into account the clustering of observations on study location and mothers. RESULTS: Although female physicians intended to breastfeed 56% of the infants for at least 12 months and 97% of infants were breastfed at birth, only 34% of infants continued to receive breast milk at 12 months. Duration of lactation among female physicians correlated with the following work-related factors: (1) not having to make up missed call/work that occurred as result of pregnancy or maternity leave; (2) longer length of maternity leave; (3) sufficiency of time at work for milk expression; and (4) perceived level of support for breastfeeding efforts at work from colleagues, program director, or division/section chiefs. CONCLUSION: Our findings support the importance of work-related factors in breastfeeding maintenance among female physicians and suggest that a tailored intervention, providing time and institutional encouragement, might result in significant improvement in their breastfeeding duration.

Pediatric Faculty Engagement and Associated Areas of Worklife After a COVID19 Surge.

Purpose: Healthcare organizations strive to increase physician engagement and decrease attrition. However, little is known about which specific worklife areas may be targeted to improve physician engagement or retention, especially after stressful events such as a COVID19 surge. Our objective was to identify demographic characteristics and worklife areas most associated with increased physician engagement and decreased intent to leave in pediatric faculty. Patients and Methods: In September 2020, we conducted a cross-sectional survey of faculty at an academic, tertiary-care children's hospital. A convenience and voluntary sampling approach was used. The survey included demographics, Maslach Burnout Index-Human Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS). The MBI-HSS was used to measure faculty engagement. The AWS measures satisfaction with six worklife areas (workload, control, reward, fairness, community, values). We used bivariate analyses to examine relationships between worklife areas and engagement and between worklife areas and intent to leave. We included multivariate logistic regression models to examine worklife areas most associated with increased work engagement and decreased intent to leave. Results: Our response rate was 41% (113/274 participants). In bivariate analysis, engaged faculty reported higher satisfaction in all worklife areas. In multivariate analyses, positive perceptions of workload (odds ratio (OR) 2.83; 95% confidence interval (CI), 1.2-6.9), control (OR, 3.24; 95% CI 1.4-7.3), and community (OR, 6.07; 95% CI 1.9-18.7) were associated with engagement. Positive perceptions of values (OR, 0.07; 95% CI 0.02-0.32) and community (OR, 0.19; 95% CI 0.05-0.78) were negatively associated with intent to leave. Conclusion: We found that positive perceptions of workload, control, and community were most associated with engagement. Alignment of values and increased sense of community were associated with decreased intent to leave. Our findings suggest specific worklife areas may be targeted to increase faculty engagement and retention.

Implementation and Maturity of Clinical Learning Environment Components Across Pediatric Residency Programs.

OBJECTIVE: Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally. METHODS: We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium. RESULTS: Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than nonrequired components. CONCLUSIONS: To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies.

Improving teaching on an inpatient pediatrics service: a retrospective analysis of a program change.

BACKGROUND: The traditional role of the faculty inpatient attending providing clinical care and effectively teaching residents and medical students is threatened by increasing documentation requirements, pressures to increase clinical productivity, and insufficient funding available for medical education. In order to sustain and improve clinical education on a general pediatric inpatient service, we instituted a comprehensive program change. Our program consisted of creating detailed job descriptions, setting clear expectations, and providing salary support for faculty inpatient attending physicians serving in clinical and educational roles. This study was aimed at assessing the impact of this program change on the learners' perceptions of their faculty attending physicians and learners' experiences on the inpatient rotations. METHODS: We analyzed resident and medical student electronic evaluations of both clinical and teaching faculty attending physician characteristics, as well as resident evaluations of an inpatient rotation experience. We compared the proportions of "superior" ratings versus all other ratings prior to the educational intervention (2005-2006, baseline) with the two subsequent years post intervention (2006-2007, year 1; 2007-2008, year 2). We also compared medical student scores on a comprehensive National Board of Medical Examiners clinical subject examination pre and post intervention. RESULTS: When compared to the baseline year, pediatric residents were more likely to rate as superior the quality of didactic teaching (OR=1.7 [1.0-2.8] year 1; OR=2.0 [1.1-3.5] year 2) and attendings' appeal as a role model (OR=1.9 [1.1-3.3] year 2). Residents were also more likely to rate as superior the quality of feedback and evaluation they received from the attending (OR=2.1 [1.2-3.7] year 1; OR=3.9 [2.2-7.1] year 2). Similar improvements were also noted in medical student evaluations of faculty attendings. Most notably, medical students were significantly more likely to rate feedback on their data gathering and physical examination skills as superior (OR=4.2 [2.0-8.6] year 1; OR=6.4 [3.0-13.6] year 2). CONCLUSIONS: A comprehensive program which includes clear role descriptions along with faculty expectations, as well as salary support for faculty in clinical and educational roles, can improve resident and medical student experiences on a general pediatric inpatient service. The authors provide sufficient detail to replicate this program to other settings.

A Pilot Study of Patient Photographs and Handoff Communication.

BACKGROUND AND OBJECTIVES: Safe and effective handoffs have become a national priority. Given that patient photographs have been associated with safety benefits in other settings, we hypothesize they could improve handoff communication. Our objective was to determine whether patient photographs used during simulated handoffs improves information retention, response to clinical scenarios, and familiarity with patients, compared with simulated handoffs without photographs. METHODS: We conducted a pilot mixed-methods study using simulated handoff sessions with pediatric residents. One investigator simulated 2 verbal handoff sessions with participants randomized to receive stock patient photographs in either the first or second session. Participants answered an online questionnaire after each session to assess information recall and familiarity with patients. Primary outcomes included percent correct responses and response time. Participants were interviewed to assess the benefits and challenges of using photographs in handoffs. RESULTS: Forty pediatric residents participated. Correct responses and response time did not differ significantly between sessions. Participants indicated less confusion and more comfort caring for patients after photograph handoff sessions. All participants identified benefits to using patient photographs and 75% identified challenges. Benefits included assisting memory, enhancing connection with patients, and improving patient safety. Challenges included visual distraction, bias concerns, and patient privacy. CONCLUSIONS: In this pilot study, patient photographs did not result in improved information retention or efficiency of response to clinical scenarios but were associated with perceptions of reduced confusion and enhanced comfort. Participants identified benefits and challenges of incorporating photographs in handoffs that could inform use in real-world settings.

Clinician-family relationships may impact neonatal intensive care: clinicians' perspectives.

OBJECTIVE: Collaborative clinician-family relationships are necessary for the delivery of successful patient- and family-centered care (PFCC) in the NICU. Challenging clinician-family relationships may undermine such collaboration and the potential impacts on patient care are unknown. STUDY DESIGN: Consistent caregivers were surveyed to describe their relationships and collaboration with families of infants hospitalized ≥ 28 days. Medical record review collected infant and family characteristics hypothesized to impact relationships. Mixed methods analysis was performed. RESULTS: Clinicians completed 243 surveys representing 77 families. Clinicians reported low collaboration with families who were not at the bedside and/or did not speak English. Clinicians perceived most clinician-family relationships impact the infant's hospital course. Negative impacts included communication challenges, mistrust or frustration with the team and disruptions to patient care. CONCLUSION: This study identifies features of clinician-family relationships that may negatively impact an infant's NICU stay. Targeting supports for these families is necessary to achieve effective PFCC.

Changes in Pediatric Faculty Burnout During the COVID-19 Pandemic.

OBJECTIVES: To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated workflow changes, such as deployment on pediatric faculty burnout in an early epicenter of the pandemic. We hypothesized burnout would increase during the COVID-19 surge. METHODS: We conducted serial cross-sectional surveys of pediatric faculty at an academic, tertiary-care children's hospital that experienced a COVID-19 surge in the Northeastern United States. Surveys were administered pre-surge (February 2020), during the surge (April 2020), and postsurge (September 2020). The primary outcome was burnout prevalence. We also measured areas of worklife scores. We compared responses between all 3 survey periods. Continuous variables were analyzed by using Student's t or Mann-Whitney tests, and categorical variables were analyzed by using χ2 or Fisher's exact test, as appropriate. RESULTS: Our response rate was 89 of 223 (40%) presurge, 100 of 267 (37%) during the surge, and 113 of 275 (41%) postsurge. There were no differences in demographics, including sex, race, and academic rank between survey periods. Frequency of burnout was similar in all 3 periods (20% to 26%). The mean scores of emotional exhaustion improved during the surge (2.25 to 1.9; P = .04). CONCLUSIONS: Contrary to our hypothesis, we found no changes in pediatric faculty burnout after a COVID-19 surge. Emotional exhaustion improved during the COVID-19 surge. However, these findings represent short-term responses to the COVID-19 surge. Longer-term monitoring of the impact of the COVID-19 surge on pediatric faculty burnout may be necessary for health care organizations to mitigate burnout.

Educational Priorities for Providing End-of-Life Care: Parent Perspectives.

OBJECTIVES: Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child's end-of-life (EOL) care. METHODS: English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process. RESULTS: Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child's EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges. CONCLUSIONS: We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care.