What do residents learn by meeting with families of children with disabilities?: A qualitative analysis of an experiential learning module

Factors Influencing Physician Prognosis: A Scoping Review

Introduction. Prognosis is an essential component of informed consent for medical decision making. Research shows that physicians display discrepancies in their prognostication, leading to variable, inaccurate, optimistic, or pessimistic prognosis. Factors driving these discrepancies and the supporting evidence have not been reviewed systematically. Methods. We undertook a scoping review to explore the literature on the factors leading to discrepancies in medical prognosis. We searched Medline (Ovid) and Embase (Ovid) databases for peer-reviewed articles from 1970 to 2017. We included articles that discussed prognosis variation or discrepancy and where factors influencing prognosis were evaluated. We extracted data outlining the participants, methodology, and prognosis discrepancy information and measured factors influencing prognosis. Results. Of 4,723 articles, 73 were included in the final analysis. There was significant variability in research methodologies. Most articles showed that physicians were pessimistic regarding patient outcomes, particularly in early trainees and acute care specialties. Accuracy rates were similar across all time periods. Factors influencing prognosis were clustered in 4 categories: patient-related factors (such as age, gender, race, diagnosis), physician-related factors (such as age, race, gender, specialty, training and experience, attitudes and values), clinical situation-related factors (such as physician-patient relationship, patient location, and clinical context), and environmental-related factors (such as country or hospital size). Discussion. Obtaining accurate prognostic information is one of the highest priorities for seriously ill patients. The literature shows trends toward pessimism, especially in early trainees and acute care specialties. While some factors may prove difficult to change, the physician's personality and psychology influence prognosis accuracy and could be tackled using debiasing strategies. Exposure to long-term patient outcomes and a multidisciplinary practice setting are environmental debiasing strategies that may warrant further research.

Highlights

Literature on discrepancies in physician's prognostication is heterogeneous and sparse.Literature shows that physicians are mostly pessimistic regarding patient outcomes.Literature shows that a physician's personality and psychology influence prognostic accuracy and could be improved with evidence-based debiasing strategies.Medical specialty strongly influences prognosis, with specialties exposed to acutely ill patients being more pessimistic, whereas specialties following patients longitudinally being more optimistic.Physicians early in their training were more pessimist than more experienced physicians.

The Impact of Caring for Children With Severe Neurological Impairment on Clinicians

Clinicians face many challenges in caring for children with severe neurological impairment (SNI). This study aimed to understand expert clinician perspectives on the personal impact of caring for children with SNI to highlight the challenges and potential solutions by underscoring the aspects of care that can be sustaining. Twenty-five clinicians participated including physicians (n = 8, 32%), social workers (n = 5, 20%), nurses/nurse practitioners (n = 5, 20%), case managers (n = 3, 12%), developmental therapists (n = 2, 8%), and other psychosocial clinicians (n = 2, 8%). Clinicians represented a variety of specialties including complex care/hospitalists (n = 10, 19%), palliative care (n = 7, 13%), and critical care (n = 6, 12%). Thematic content analysis revealed 3 major themes: (1) worries and challenges; (2) positive impact from being present; and (3) personal growth and meaning-making. Many clinicians described the ways listening, examining biases, learning about family perspectives, and normalizing the need for emotional processing helped them to understand their patients, families, and themselves more deeply.

What’s in Your Culture? Embracing Stability and the New Digital Age in Moving Colleges of Health Professions Virtually during the COVID-19 Pandemic: An Experiential Narrative Review

As traditional education transitioned from face-to-face interactions to virtual learning during the COVID-19 pandemic, faculty and staff in dental hygiene, nursing, and exercise science programs placed students at the center of every educational decision and promoted stability in learning with their commitments to excellence in teaching and the delivery of content using educational and communication technology. This experiential narrative review explains how faculty members and administrators addressed online education with technology specific to health professions and how universities managed to assist students with innovative services for mental health. It also provides an insight into how degree-specific academic personnel embraced technology-based hands-on activities in community health clinics and clinical laboratories, with sustainable and impactful lessons in equity, affordability, and transformative education. Finally, health administrators gather their top-10 leadership recommendations to continue moving forward during the pandemic and present a unique self-reflection on the process of caring considerations required for a successful experience for faculty members, staff, and students.

Visiting Jack: Mixed Methods Evaluation of a Virtual Home Visit Curriculum With a Child With Medical Complexity

BACKGROUND

There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents.

OBJECTIVE

1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents' confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum.

METHODS

This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and postassessments were compared using paired t tests. Follow-up interviews and focus groups were performed 5 to 8 weeks after training. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all P < .001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, and 4) commitment to change practice.

CONCLUSIONS

Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.

The Resident Experience of an Obesity-Focused Home Visiting Curriculum

BACKGROUND

The prevalence of obesity in the USA has risen to 39.8% of adults and 18.5% of children, yet there has not been a compensatory rise in residency training to reflect this epidemic.

OBJECTIVES

To examine pediatric residents' lived experiences of completing a novel home visitation curriculum for children with obesity in resource-poor areas of Washington, DC.

METHODS

Pediatric residents completed a home visiting curriculum consisting of four modules followed by two home visits to families with a child struggling with obesity. Within 2 weeks of completing the curriculum, individual interviews were conducted with participants about their experience. Inductive coding was used to analyze the data, followed by clustering and theming.

RESULTS

Saturation was reached after individual interviews with 13 residents between 2013 and 2015. Five themes emerged describing the residents' experiences: (1) enhanced understanding of home and community life, (2) awareness of personal biases and assumptions, (3) challenges of losing control and not being intrusive, (4) deeper relationship and enhanced empathy with patient and family, and (5) changes in delivery of care.

CONCLUSIONS

The findings from this study suggest that an obesity-focused home visiting curriculum may provide residents with a deeper understanding of social determinants of obesity and the opportunity to gain other necessary skills that may help them better care for individuals with obesity.

Physician and Parental Decision-Making Prior to Acute Medical Paediatric Admission

Background: The number of acute medical paediatric emergency admissions is rising. We undertook qualitative interviews with parents and clinicians to better understand what factors, other than the health status of the child, may influence decision making leading to emergency admission. Methods: Semi-structured interviews were conducted with parents; clinicians working in general practice, out-of-hours or the emergency department (referring clinicians); and doctors working in acute medical paediatrics (receiving clinicians). Results: Ten parents, 7 referring clinicians and 10 receiving clinicians were interviewed. Parents described “erring on the side of caution” when seeking medical opinion and one mentioned anxiety. Among themes seen among referring clinicians, “erring on the side of caution” was also identified as was managing “parental anxiety” and acting on “gut instinct”. Among receiving clinicians, themes included managing parental anxiety and increasing parental expectations of the health service. Conclusions: The study of parent and referring clinician decision-making prior to a hospital admission can identify “teachable moments” where interventions might be delivered to slow or even arrest the rise in short-stay acute medical admissions in Britain and other countries. Interventions could assure parents or referring clinicians that hospital referral is not required and help clinicians understand what they perceive as “parental anxiety”.

What Do Pediatric Residents Gain From an Experience in Juvenile Justice? A Qualitative Analysis of Community-Based Learning

BACKGROUND

Training in advocacy and community pediatrics often involves the use of community site visits. However, data on the specific knowledge, skills, and attitudes gained from these experiences are limited. In this study we used qualitative analysis of written narratives to explore the response of residents to a juvenile justice experience.

METHODS

Pediatric residents participated in a week-long experience in the juvenile probation department and completed a written narrative. Narratives were analyzed using grounded theory to explore the effects of this experience on residents' views of youth in the juvenile justice system.

RESULTS

Analysis of 29 narratives revealed 13 themes relating to 5 core concepts: social determinants of behavior, role of professionals and institutions, achieving future potential, resolving discrepancies, and distancing. A conceptual model was developed to explore the interactions of these concepts in the resident view of youth in the juvenile justice system. Of the themes only 3 (23%) were related to content explicitly covered in the assigned reading materials.

CONCLUSIONS

Several important concepts emerged as elements of this experience, many of which were not covered in the explicit curriculum. Variability in attitudinal response to the experience raised important questions about the influence of the ideological framework of the learner and the hidden curriculum on the learning that occurs in community settings. We propose a theoretical model that delineates the factors that influence learning in community settings to guide educators in planning these types of experiences.

Healthy Homes, Healthy Futures: A Home Visitation Curriculum for Pediatric Residents

INTRODUCTION

A working knowledge of the home and neighborhood environment is critical to understanding the barriers that families face when struggling with obesity. Most doctors are only given the opportunity to address individuals with obesity in the office setting and usually describe their counseling abilities as ineffective. This focused home visitation curriculum offers a unique tool to improve residents' understanding of the social determinants of health, how these determinants relate to obesity, and critical obesity-management skills.

METHODS

The curriculum requires residents to review three PowerPoint modules and an article on motivational interviewing. Residents then implement what they have learned by doing two home visits with a family from their continuity clinic and completing a windshield survey of the family's neighborhood. This publication includes all of the materials necessary to facilitate the curriculum, including scripts for the residents to use at each visit, resources for the family, and curriculum evaluation tools.

RESULTS

Twenty residents who completed the curriculum reported improved counseling skills and improved understanding of the social determinants of health. During postcurriculum qualitative interviews, residents described the experience as eye-opening and revealed that lessons learned from the visits will alter how they approach patients who are obese in their future clinical practice.

DISCUSSION

The program has been integrated into our pediatric residency curriculum and completed during a first-year community health rotation, but it could be completed at any time during resident training.

Preparing Tomorrow's Doctors to Care for Patients With Autism Spectrum Disorder

People with autism spectrum disorder (ASD) and other developmental disabilities have poorer health and face unique barriers to health care compared to people without disabilities. These health disparities can be partially attributed to physicians' limited knowledge about caring for patients with developmental disabilities. The purpose of this study was to determine the effectiveness of ASD training for medical students. Our training included a lecture and a panel presentation that featured people with ASD and family members. Students reported improved knowledge, skills, confidence, and comfort in caring for patients with ASD.

Interventions aimed at increasing knowledge and improving attitudes towards people with intellectual disabilities among lay people

Despite policies aimed at ensuring equal rights and maximising respect and social inclusion for people with intellectual disabilities, in their daily lives many continue to face negative attitudes and discrimination within society. Misconceptions about what it means to have an intellectual disability and about the capabilities of people with intellectual disabilities appear widespread, and may contribute to prejudice and discrimination. This review provides a summary and evaluation of empirical interventions aimed at increasing knowledge and targeting negative attitudes towards this population among lay people of working age. An electronic search using PsycINFO, Web of Science and PubMed identified 22 English language studies published between 1990 and early 2014 that reported a specific intervention with a lay population sample. The majority of studies reported promising outcomes, particularly those aimed at increasing knowledge of intellectual disability through education. Support for the positive influence of contact with people with intellectual disabilities was demonstrated across several interventions. Interventions delivered at least partly by individuals with intellectual disabilities, and educational interventions appear to hold the most promise. The evidence is limited though by the weaknesses of measurement tools employed.

Measuring staff empowerment regarding health care for clients with intellectual disabilities

Background. Women with intellectual disabilities (ID) contract breast cancer at the same rate as the general population but have higher breast cancer mortality and lower rates of breast cancer screening. Many women with ID live in group homes or supported residences where they are cared for by direct support workers. While direct support workers are thought to influence client health, this effect is underresearched, and we lack tools for measuring staff empowerment and perceptions regarding client health. Methods. We developed and validated an instrument, the staff empowerment tool (SET), to measure staff empowerment as related to supporting clients in preventive health. Results. The SET was found to be a reliable instrument for measuring staff activation and empowerment in helping clients access mammography screening. Discussion. Quantifying staff empowerment and perspectives is important in studying and reducing disparities among adults with ID, a vulnerable population. Further research to determine the impact of staff empowerment levels on their clients' health and health care access is suggested. The SET is a valuable tool for measuring the construct of staff empowerment, evaluating interventions, and collecting data regarding variation in staff empowerment.

"Sometimes I feel overwhelmed": educational needs of family physicians caring for people with intellectual disability

Primary care physicians who care for adults with intellectual disability often lack experience with the population, and patients with intellectual disability express dissatisfaction with their care. Establishing a secure primary care relationship is particularly important for adults with intellectual disability, who experience health disparities and may rely on their physician to direct/coordinate their care. The authors conducted semistructured interviews with 22 family physicians with the goal of identifying educational needs of family physicians who care for people with intellectual disability. Interviews were transcribed and coded using tools from grounded theory. Several themes related to educational needs were identified. Physician participants identified themes of "operating without a map," discomfort with patients with intellectual disability, and a need for more exposure to/experience with people with intellectual disability as important content areas. The authors also identified physician frustration and lack of confidence, compounded by anxiety related to difficult behaviors and a lack of context or frame of reference for patients with intellectual disability. Primary care physicians request some modification of their educational experience to better equip them to care for patients with intellectual disability. Their request for experiential, not theoretical, learning fits well under the umbrella of cultural competence (a required competency in U.S. medical education).

Identifying what pediatric residents are taught about children and youth with special health care needs and the medical home

OBJECTIVE

To describe what and how pediatric residents in Massachusetts are taught about children and youth with special health care needs (CYSHCN) and the medical home.

PARTICIPANTS AND METHODS

Faculty members and residents at Massachusetts' 5 pediatric residency programs were interviewed to identify current curricula and teaching methods related to care of CYSHCN. In addition, residents were surveyed to quantify these concepts.

RESULTS

Thirty-one faculty members and 25 residents were interviewed. Most exposure to CYSHCN was reported to occur in inpatient settings. However, most formal teaching about CYSHCN was described as occurring in the ambulatory setting. Promising educational strategies included home and community visits, inclusion of CYSHCN in resident continuity panels, and simulation and role-playing. Overall, the programs had little training emphasis on the lives and needs of CYSHCN and their families outside the hospital setting. Twenty (80%) of the residents interviewed completed the written survey instrument. They noted a high degree of comfort in caring for CYSHCN in various settings and involving families in decision-making about their child's care but expressed less comfort in identifying community resources and collaborating with community agencies and schools.

CONCLUSIONS

Programs offer a variety of successful educational and clinical experiences related to the medical home and CYSHCN. The results of our study indicate that residents and faculty members believe that residents would benefit from more formal training opportunities to learn directly from families and community representatives about caring for CYSHCN.

Pediatric resident attitudes toward caring for children with severe disabilities

OBJECTIVE

To survey pediatric residents' attitudes toward caring for children with severe disabilities.

DESIGN

A cross-sectional survey of residents in a university-affiliated pediatric residency program between October and December 2005. Residents were asked to complete a newly designed, 13-item survey. For each item, participants selected the degree to which they did or did not agree with a statement about disabilities or caring for children with severe disabilities.

RESULTS

Fifty-five (43%) of 129 eligible residents participated. Eighty-nine percent felt that caring for children with severe disabilities was as rewarding as caring for other children. Ninety-two percent felt that there is a societal responsibility to care for such children; 98% felt families of children with disabilities love their children as much as other families. Two-thirds (66%) admitted frustration related to caring for children who cannot be cured or function independently, and 71% questioned the aggressive treatment of such children. Residents in their second and third postgraduate years were more likely to question the aggressive treatment compared with their junior colleagues.

CONCLUSIONS

Although pediatric residents had positive attitudes toward children with severe disabilities, emotional and moral tensions did arise around their care.

Medical education and disability studies

The biomedicalist conceptualization of disablement as a personal medical tragedy has been criticized by disability studies scholars for discounting the difference between disability and impairment and the ways disability is produced by socio-environmental factors. This paper discusses prospects for partnerships between disability studies teaching/research and medical education; addresses some of the themes around the necessity of critical disability studies training for medical students; and examines a selection of issues and themes that have arisen from disability education courses within medical schools globally. The paper concludes that providing there is a commitment from senior management, universities are well positioned to apply both vertical and horizontal approaches to teaching disability studies to medical students.