Training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study

Use of "Bug-in-the-Ear" Technology in Improving Pediatric Residents' Skills in Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder

OBJECTIVE

To improve pediatric residents' skills in the diagnosis and treatment of children with Attention Deficit Hyperactivity Disorder (ADHD) by giving real-time feedback utilizing Bug-in-the-Ear technology (BIE).

METHODS

This prospective, controlled study had two treatment groups and three standardized patient (SP) sessions. Session-1 was baseline. In Session-2, the intervention group (IG) received feedback via BIE and the control group (CG) received traditional feedback. Session-3 (3 months later) assessed maintenance of skills, and neither group used BIE. Sessions were recorded and scored by research assistants trained with a novel scoring system called the Clinical Practice Index (CPI). The CPI is an observational instrument based on current American Academy of Pediatrics (AAP) ADHD guidelines and DSM-5 criteria for ADHD and was reviewed by content experts in ADHD. CPI scores were analyzed using Repeated Measures ANOVA.

RESULTS

Twenty-five pediatric residents participated; 13 in the CG and 12 in the IG. Maximum obtainable CPI score was 44 points. The IG showed a significant increase in their CPI score from Session-1 to Session-3 (8.27, P<0.001). The CG's CPI scores from Session-1 to Session-3 did not change significantly (2.85, P=0.536). The IG and CG CPI scores were significantly different at Session-2 (11.7, P<0.001), but not Session-3 (5.03, P=0.1407).

CONCLUSION

Immediate feedback via BIE showed significant improvement in the IG's skills in Session-2 and the IG's mean difference between Session-1 and Session-3. One exposure of BIE was not sufficient for the IG to maintain their skills, and further research is warranted to determine the number of BIE exposures needed for greater maintenance of skills.

Does Early Exposure Change Pediatric Residents' Perceptions of Developmental-Behavioral Pediatric Care?

OBJECTIVE

To explore the impact of a new "Intro to DBP" rotation on pediatric residents' interest in developmental-behavioral pediatrics (DBP) and comfort in providing DBP care.

METHODS

All first-year pediatric residents participated in a new 1-week DBP rotation. Experiences included clinic visits; interdisciplinary evaluations; asynchronous online learning; and lectures, journal clubs, and/or case conferences. Participants completed pre- and postrotation surveys. Surveys focused on awareness of the DBP field; career plans; and perceived importance of, comfort with, and interest in learning about DBP care. We analyzed data using descriptive statistics and Bhapkar's test to compare distribution differences on pre- and postrotation Likert scales; we reviewed open-ended questions to identify themes.

RESULTS

Thirty-two residents participated; 56% had no previous exposure to DBP. After the rotation, there was a statistically significant increase in resident-reported importance of DBP care (p < 0.0001), comfort in providing DBP care (p < 0.0001), and interest in pursuing a DBP fellowship (p = 0.0048). Themes identified from open-ended responses suggested that the rotation led to a broader understanding of the DBP field, reinforcement and expansion of knowledge pertinent to all pediatric care, and improved understanding of systems of care.

CONCLUSION

Brief, early exposure to DBP during pediatric residency training led to increased awareness of and comfort in providing DBP care. Residents described a broader understanding of the depth and breadth of DBP and its applicability to all aspects of pediatric care. Early introduction to DBP during residency training may stimulate greater interest in the field and greater comfort among general pediatricians to provide DBP care.

Scoping Review of Pediatric Primary Care Educational Literature

Primary care pediatrics is an important element of pediatric training at all levels, yet trainees often lack clinical competence in this area. This scoping review sought to identify the current research available related to pediatric primary care education for medical students and residents and gaps/areas for improvement. Searches were completed on PubMed MEDLINE, Embase, Scopus, and MedEdPORTAL using the search terms "pediatrics," "education," "curricula," and "primary care." An initial total of 6499 articles was screened down to 102 articles for the final full text review and extraction. The most frequently encountered educational subjects were child development and developmental screening (8.8%), adolescent substance use (7.8%), and vaccines/vaccine hesitancy (6.9%). Several subject areas were underrepresented, including pubertal assessment (0.9%), transgender medicine (0.9%), child passenger safety (0.9%), discipline (0.9%), and sports/orthopedic medicine (0%). This study shows that future pediatric primary care educational studies and innovations are needed to improve trainee competence and comfort.

Child Health Needs and the Developmental-Behavioral Pediatrics Workforce Supply: 2020-2040

Developmental-behavioral pediatrics (DBP) subspecialists care for children with complex neurodevelopmental and behavioral health conditions; additional roles include education and training, advocacy, and research. In 2023, there were 1.0 DBP subspecialists per 100 000 US children aged 0 to 17 years (range 0.0-3.8), with wide variability in DBP subspecialist distribution. Given the prevalence of DB conditions, the current workforce is markedly inadequate to meet the needs of patients and families. The American Board of Pediatrics Foundation led a modeling project to forecast the US pediatric subspecialty workforce from 2020 to 2040 using current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios and reports results in headcount (HC) and HC adjusted for percent time spent in clinical care, termed "clinical workforce equivalent." For DBP, the baseline model predicts HC growth nationally (+45%, from 669 to 958), but these extremely low numbers translate to minimal patient care impact. Adjusting for population growth over time, projected HC increases from 0.8 to 1.0 and clinical workforce equivalent from 0.5 to 0.6 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. Even in the best-case scenario (+12.5% in fellows by 2030 and +7% in time in clinical care), the overall numbers would be minimally affected. These current and forecasted trends should be used to shape much-needed solutions in education, training, practice, policy, and workforce research to increase the DBP workforce and improve overall child health.

Assessment and Management of Attention-Deficit/Hyperactivity Disorder: Pediatric Resident Perspectives on Training and Practice

Attention-deficit/hyperactivity disorder (ADHD) is a common presenting concern in primary care. This study examined the relationship between pediatric residency training program characteristics and residents' ADHD knowledge, attitudes, and comfort in providing ADHD services. Given the familiarity that pediatric chief residents have with the training and experiences within their residency programs, a 30-item survey was mailed to pediatric chief residents. A total of 100 residents returned their surveys (response rate 49.5%) and were included in the descriptive quantitative and thematic qualitative analyses. The majority of participants rated their ADHD knowledge as at least average. However, approximately half of the participants were comfortable with screening, and less than half were comfortable with managing stimulant medication or behavioral treatments. Participants emphasized the importance of interprofessional collaboration, clinical experiences, and integrated ADHD education throughout training. These results emphasize the importance of improved training in screening, diagnosing, and managing ADHD to increase resident comfort regarding these practices.

Is corticophobia spreading among pediatricians?-Insights from a self-efficacy survey on the management of pediatric atopic dermatitis

Background

Atopic dermatitis (AD) is a chronic dermatological condition, often diagnosed and managed by pediatricians. However, pediatricians have difficulties with adhering to guidelines, which recommend the use of topical corticosteroids (TCS) as a first-line treatment and oral corticosteroids (OCS) for resistant cases. Our aim was to assess pediatricians' self-confidence in using steroids in the management of pediatric AD, and investigate which characteristics are related to high self-confidence in prescribing corticosteroids (CS).

Methods

We conducted a cross-sectional questionnaire study among Israeli pediatricians between April 2022 and June 2022. Participants were asked to answer questions dealing with self-assessment of prescribing CS in the management of AD.

Results

A total of 171 residents and pediatricians participated in the survey; 86.6% and 28.1% admitted feeling either average or below-average confidence in the prescription of OCS and TCS, respectively. Physicians who were exposed to higher AD patients (P=0.048) and worked at the clinics (88.2% vs. 60.4%, P<0.001) had high self-confidence in treating AD with TCS. Males (20.3% vs. 8%, P=0.03), and having gone to medical school outside Israel (22.2% vs. 10.4%, P=0.09) were all related to high self-efficacy in prescribing OCS. In total, 11.7% of participants confessed to refraining from prescribing steroids because of fear of side effects.

Conclusions

Most pediatricians have below-average confidence in prescribing OCS for the treatment of AD. Males, working in a community setting, and previous exposure improve the confidence level and can be easily considered in future pediatric training programs.

Israeli pediatricians' confidence level in diagnosing and treating children with skin disorders: a cross-sectional questionnaire pilot study

Background

Pediatricians daily see large numbers of patients with skin disorders. However, they encounter limited guidance as a result of a marked deficiency in pediatric dermatologists. Hence, reevaluation of training opportunities during pediatric residency has become essential. Our aim was to evaluate the confidence level of pediatric residents and specialists in diagnosing and treating skin disorders in children and to determine career and training-related characteristics that influence it.

Methods

Conducted as a cross-sectional study, we administered a questionnaire to 171 pediatricians across Israel. We assessed respondents' self-efficacy about their ability to diagnose and treat skin disorders and collected data regarding their previous dermatology training and preferred training methods.

Results

77.8% of respondents reported below or average self-efficacy scores in diagnosing and managing children with skin disorders. Older age (>40 years old; OR = 5.51, p = 0.019), treating a higher number of patients with skin disorders (OR = 2.96, p = 0.032), and having any training in dermatology, either during medical school or residency (OR = 7.16, p = 0.031, OR = 11.14, p = 0.003 respectively), were all significant parameters involved in pediatricians reporting high self-efficacy in skin disorder management.

Conclusion

Most pediatric residents and pediatricians have average or below-average confidence in managing pediatric skin disorders. We suggest incorporating dermatology rotations during pediatric residency to improve young pediatricians' self-efficacy in managing skin disorders and ultimately help pediatricians provide better care for patients presenting with dermatological conditions. These findings can ultimately help refine a pilot program in dermatology that might be implemented during pediatric residency.

Be ExPeRT (Behavioral Health Expansion in Pediatric Residency Training): A Case-Based Seminar

Introduction

Pediatric residents report behavioral or mental health (B/MH) assessment and treatment as a training gap and often feel ill-equipped to address these issues in clinical practice. We developed a novel interactive training program to improve resident confidence in managing common pediatric B/MH conditions.

Methods

The Be ExPeRT curriculum comprised a half-day interactive seminar on attention deficit hyperactivity disorder, anxiety, depression, and suicidality followed by monthly case-based discussions. Content included didactic material, role-play, and case discussion. The training was optional and open to pediatric or combined medicine-pediatrics trainees.

Results

Twenty-three residents (70% female) participated in four separate seminars over 2 years. Of the participants attending the seminars, 17 (74%) completed the presurvey, and 16 (70%) completed the postsurvey. Statistically significant improvement was noted in comfort treating major depressive disorder (41% pre, 94% post, p = .002), suicide risk (29% pre, 94% post, p < .001), and anxiety (24% pre, 94% post, p < .001) following program participation. Twelve (75%) of the 16 participants completing the survey rated the training in the top 5%-10% with respect to other resident learning experiences.

Discussion

We developed this curriculum to enhance trainee knowledge and comfort in addressing common pediatric B/MH conditions in primary care. Significant improvement was noted in self-reported comfort in treating major depressive disorder, suicide risk, and anxiety, and the program was well received. The curriculum can be adapted for use in any training program for primary care providers to provide B/MH education that may be lacking or supplement existing programming.

A Comprehensive Outpatient Pediatric Resident Complex Care Curriculum

Introduction

Pediatric resident training typically prepares learners to care for children with medical complexity (CMC) when acutely ill; however, residents often do not receive formal primary care training for this population. We designed a curriculum to improve pediatric resident knowledge, skills, and behavior when providing a medical home for CMC.

Methods

Guided by Kolb's experiential cycle, we designed and offered a complex care curriculum as a block elective to pediatric residents and pediatric hospital medicine fellows. Participating trainees completed a prerotation assessment to establish baseline skills and self-reported behaviors (SRB) and four pretests to document baseline knowledge and skills. Residents viewed online didactic lectures weekly. During four half-day patient care sessions per week, faculty reviewed documented assessments and plans. Additionally, trainees attended community-based site visits to appreciate the socioenvironmental perspective of CMC families. Trainees completed posttests and a postrotation assessment of skills and SRB.

Results

Between July 2016 and June 2021, 47 trainees participated in the rotation, with data available for 35 trainees. Residents demonstrated significant improvement in knowledge (p < .001), self-assessed skills (average Likert-scale rating prerotation = 2.5 vs. postrotation = 4.2), and SRB (average Likert-scale rating prerotation = 2.3 vs. postrotation = 2.8) based on test scores and trainees' postrotation self-assessments. Learner evaluations of the rotation site visits (15 out of 35, 43%) and video lectures (eight out of 17, 47%) demonstrated overwhelmingly positive reaction.

Discussion

This comprehensive outpatient complex care curriculum addressing seven of 11 nationally recommended topics demonstrated improvement in trainees' knowledge, skills, and behaviors.

Brief Focused Interprofessional Encounters in a Developmental-Behavioral Rotation Facilitate Pediatric Resident Experiences, Foster Interprofessional Relationships, and Improve Confidence in Mental Health and High-Risk Developmental Conditions

Experiences with mental health (MH) and high-risk developmental conditions (HRDC) are challenging to obtain during pediatric residency. This study describes Brief Focused Interprofessional Encounters (BFIE) during a developmental-behavioral pediatric (DBP) rotation. Postgraduate year 1 (PGY1) pediatric residents recorded diagnoses of children they interacted with at each BFIE site and completed a self-assessment at the start and end of their rotation. Of 48 residents, 67% (32/48) completed daily encounter records and 81% (39/48) completed self-assessment surveys. Residents' self-reports showed significantly higher levels of confidence in 12 learning areas, with the highest gains in bereavement, autistic spectrum disorders, juvenile justice, and teen pregnancy (Ps < .001). By establishing BFIE customized to the local community, a DBP curriculum can effectively provide measurable, innovative curriculum content that addresses less commonly accessed areas of MH and HRDC; foster interprofessional relationships; and improve resident confidence.

Helping Our Toddlers, Developing Our Children's Skills: Innovative Behavioral Management Training for Pediatric Residents

This article describes the implementation of a behavioral management training program into pediatric and combined medicine-pediatric residencies at a large urban academic medical center in southwest Florida. We describe 2 modalities for training residents in effective behavioral modification strategies immediately useable in pediatric practice. Results indicate that residents significantly increased their knowledge of effective, evidence-based strategies and continued to use them 6 to 12 months following completion of the training.

A Workplace Procedure Training Cart to Augment Pediatric Resident Procedural Learning

OBJECTIVE

Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients.

METHODS

Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention.

RESULTS

From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents.

CONCLUSIONS

A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.

Addressing Pediatric Developmental and Mental Health in Primary Care Using Tele-Education

This study evaluates the effectiveness of an early childhood tele-education program in preparing community pediatric clinicians to manage developmental and mental health disorders in young children. Community pediatric clinicians from rural, underserved, or school-based health center practices in the mid-Atlantic region participated in a weekly tele-education videoconference. There was a significant knowledge gain evidenced by the percentage of questions answered correctly from pre- to post- didactic exposure (P < .001). Participants reported an increase in knowledge from pre- (P < .001) and in confidence from pre- to post- participation (P < .001). Practice management changes demonstrated an encouraging trend toward managing patients in the Medical Home, as compared with immediately deferring to specialists following participation. This early childhood tele-education videoconferencing program is a promising response to the urgent need to confidently increase the role of pediatricians in the provision of care for childhood developmental and mental health disorders.

Evaluating the Keystones of Development - An Online Curriculum for Residents to Promote Positive Parenting in Primary Care

OBJECTIVE

This pilot outcome evaluation assesses the effectiveness of an online curriculum, the Keystones of Development, aimed at improving residents' knowledge, attitudes, and reported behaviors around promoting positive parenting and childhood development in well-child visits.

METHODS

We used an explanatory mixed-methods approach, including a single-arm pre-posttest of intervention effects on self-reported behavioral outcomes (discussing, modeling, and praising) and secondary outcomes (knowledge, perceived barriers, attitudes, and self-efficacy). Following this, a subset of residents participated in in-depth interviews to describe participant responses to the intervention.

RESULTS

The study was conducted at 8 pediatric residency programs across the United States with 67 pediatric residents (mean age = 29; 79% female; 57% PGY1). Within one month postintervention, there was a statistically significant increase in the behaviors that promote positive parenting: discussing (P < .01;d = 0.73) and modeling (P < .01;d = 0.61) but not praising (P = .05; d = 0.3). Significant changes in the secondary outcomes: knowledge (P < .01), perceived barriers, (P < .01), and retrospective self-efficacy (P < .01) were seen. Interviews revealed that integration of curriculum content into clinical practice was due to the relevance of the material to primary care and the modeling of how to apply in the clinical setting. Curriculum format, content, and clinical application helped participants weave recommendations into the well-child visit.

CONCLUSIONS

In this study, we demonstrated that the online curriculum, Keystones of Development, increased resident behaviors, knowledge, and self-efficacy, and decreased perceived barriers to promote parenting behaviors associated with improved child development outcomes in well-child visits. These findings were observed across participants demonstrating equal success regardless of demographic characteristics or study site.

Regulatory Requirements on the Competence of Remote Operator in Maritime Autonomous Surface Ship: Situation Awareness, Ship Sense and Goal-Based Gap Analysis

Maritime Autonomous Surface Ship (MASS) has been developed recently, and demonstration projects have been carried out internationally. Considering the full autonomous level is unlikely to be addressed shortly, remote control centre and Remote Operator (RO) will play a vital role in the MASS system. Although competence of watchkeeping at the ship’s bridge is inevitable for RO to avoid ship accidents caused by human errors, international requirements have not been introduced yet. This paper presents a way to develop the regulatory framework on the competence of RO based on the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) by exploring the concept of Situation Awareness (SA). Goal-Based Gap Analysis (GBGA) is constructed based on the human-behaviour model and the required information for SA. A case study through the mini focus group discussion with interviews by a total of three (3) veteran instructors of training ships is conducted utilising the information including the results of previous demonstration projects on the remote control. The results show the relationship between required information and ship sense, shortage of these factors when RO is operating, additional competence and possible regulatory requirements for RO. The findings support the usefulness of GBGA and pave the way to develop a regulatory framework for RO further.

A Curriculum to Improve Pediatric Residents' Telephone Triage Skills

INTRODUCTION

Telephone triage systems are frequently used due to their success in decreasing emergency department utilization, reduction of health care costs, and high levels of satisfaction among patients and providers. Despite phone triage's prevalence, few residency programs have designated curricula for residents to learn this vital skill.

METHODS

We designed a phone triage curriculum initially piloted with senior residents at one of our continuity clinics. The curriculum consisted of a didactic session, a just-in-time simulation training session, and an experiential component of being on call during the ambulatory rotation. Retrospective pre-post self-assessments evaluated resident perceptions of their skills in taking histories and triaging care over the phone in addition to obtaining qualitative feedback from faculty and residents immediately after the curriculum and 1-2 years postgraduation.

RESULTS

Of 11 eligible residents, 10 (91%) chose to participate in the pilot curriculum. Residents reported that their skills in history taking over the phone improved from 20% to 90% and their ability to triage patients over the phone improved from 0% to 80%. This led to a quality improvement initiative to increase patient calls and has continued for 5 years, with continued positive feedback from residents and attendings.

DISCUSSION

Phone triage skills are a necessity for pediatric providers, but few residency programs have training curricula in place. Through an experience-based phone triage program, residents significantly improved their self-reported skills at history taking and triaging. Similar curricula could easily be adopted at other institutions.

If You Build It, Will They Come? A Hard Lesson for Enthusiastic Medical Educators Developing a New Curriculum

BACKGROUND

Primary care forms a critical part of pediatricians' practices, yet the most effective ways to teach primary care during residency are not known.

OBJECTIVE

We established a new primary care curriculum based on Malcolm Knowles' theory of andragogy, with brief clinical content that is easily accessible and available in different formats.

METHODS

We used Kern's model to create a curriculum. In 2013, we implemented weekly e-mails with links to materials on our learning management system, including moderators' curricular content, resident-developed quizzes, and podcasts. After 3 years, we evaluated the curriculum with resident focus groups, retrospective pre-/post-resident surveys, faculty feedback, a review of materials accessed, and resident attendance.

RESULTS

From content analysis of focus groups we learned that residents found the curriculum beneficial, but it was not always possible to do the pre-work. The resident survey, with a response rate of 87% (71 of 82), showed that residents perceived improvement in 37 primary care clinical skills, with differences from 0.64 to 1.46 for scales 1-5 (P < .001 for all). Faculty feedback was positive regarding curriculum organization and structure, but patient care often precluded devoting time to discussing the curriculum. In other ways, our results were disappointing: 51% of residents did not access the curriculum materials, 51% did not open their e-mails, only 37% completed any of the quizzes, and they attended a weekly conference 46% of the time.

CONCLUSIONS

Although residents accessed the curriculum less than expected, their self-assessments reflect perceptions of improvement in their clinical skills after implementation.

The Educational Role of Autonomy in Medical Training: A Scoping Review

BACKGROUND

Recent limits imposed on autonomy have raised concern regarding the quality of medical training. The impact of autonomy on medical education has not been comprehensively reviewed. A scoping review was performed to understand the significance of autonomous practice in medical training.

METHODS

The MEDLINE and Embase databases were searched for all studies on the role of autonomy in medical training. Articles were included that referenced the medical profession or trainees, and "autonomy," "independence," or "supervision". Data were qualitatively synthesized and analyzed.

RESULTS

The search yielded 3649 articles of which 189 were included. Fourteen studies specifically investigated the role of autonomy: 10 surveys on resident perception, and four studies comparing the effect of supervision on learning outcomes. The remaining 175 publications described participant (88) or author (87) opinions regarding the benefits of autonomy as an educational strategy. One quarter (48) of the publications specifically pertained to surgical disciplines, of which one specifically investigated the role of autonomy. Common themes associated autonomy with increased confidence, readiness for independent practice, the development of clinical decision-making skills, and professional identity.

CONCLUSIONS

The current literature primarily represents the opinions of medical educators and trainees. A better understanding of the role of autonomy could inform the development of strategies to compensate for the gap left by the current context of decreased autonomy in medical training.

Modeling Framework Used to Analyze and Describe Junctional Tourniquet Skills

Medical educators have acknowledged the importance of simulation training in developing procedural skills. While simulation training in other disciplines has benefitted from evaluations of users' skill acquisition, the majority of medical training simulators continue to be developed from overly simplified descriptions of procedures, such as techniques prescribed by existing instructional material. Our objective was to use a modeling framework to characterize the skill of various users in applying junctional tourniquets in order to design an effective training simulator. We recorded 46 medical first responders performing training exercises applying a junctional tourniquet and used coded video and sensor data to identify the hierarchy of actions they performed in the process. The model provides several insights into trainee performance, such as the way in which advanced users perform more tasks in parallel, or areas where advanced users employ situational awareness to identify ways they can deviate from recommended protocol to improve outcomes. The model successfully identifies variations in tourniquet application technique that correlates with improvement on clinically relevant metrics including application speed, pressure applied, and tourniquet placement stability. This methodology can improve medical training simulations by indicating changes during the course of learning a new task, such as helpful deviations from instructional protocol.

A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care

Supplemental Digital Content is available in the text.

Background:

Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care.

Methods:

We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area.

Results:

Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing.

Conclusions:

The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.

Gaps in Developmental Pediatrics training: A Canadian resident physician perspective

This article was migrated. The article was marked as recommended. Introduction: Postgraduate medical training worldwide has recently experienced a transition to Competency-Based Medical Education (CBME). This provides a timely opportunity to critically evaluate the postgraduate medical curriculum, particularly from a trainee perspective. Studies reveal that Canadian residents and recent graduates in pediatrics and family medicine are uncomfortable with their proficiency in child development. However, little is known about residents' perceptions of their training, nor where specific needs lie. We therefore sought to identify gaps in developmental pediatrics training, with the goal of informing the development of a new CBME curriculum. Methods: An online cross sectional needs assessment survey was administered to current pediatrics and family medicine residents at our institution. A total of 63 residents participated, 43 pediatrics and 20 family medicine. Results: Four key themes emerged from analysis of survey results: 1. Residents agree that developmental pediatrics is relevant to future practice and competency; 2. Residents feel they lack competency in the assessment and management of patients with developmental issues; 3. Residents' feelings of insufficient and inadequate training increase over time; 4. Residents recommend changes to developmental pediatrics training. Conclusion: As we prepare to transition to CBME, curriculum should be purposefully developed to meet resident identified need and reflect appropriate competencies required for clinical practice.

Factors Influencing Pediatric Resident Exposure to Adolescents in their Continuity Clinic

Adequate training in adolescent primary care is a challenge for pediatric residency programs. We examined residents' pediatric continuity clinic exposure to and comfort with adolescents, and their knowledge about best practices. Comfort was predicted by patient numbers, training level, and completing the adolescent rotation. Knowledge was predicted by completing the adolescent rotation.

A Workforce Survey on Developmental-Behavioral Pediatrics

BACKGROUND AND OBJECTIVES

Developmental-behavioral conditions are common, affecting ∼15% of US children. The prevalence and complexity of these conditions are increasing despite long wait times and a limited pipeline of new providers. We surveyed a convenience sample of the developmental-behavioral pediatric (DBP) workforce to determine current practices, workforce trends, and future needs.

METHODS

An electronic survey was e-mailed to 1568 members of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics and Council on Children with Disabilities, the Society for Developmental and Behavioral Pediatrics, and the National Association of Pediatric Nurse Practitioners Developmental and Behavioral Mental Health Special Interest Group.

RESULTS

The response rate was 48%. There were 411 fellowship-trained physicians, 147 nonfellowship-trained physicians, and 125 nurse practitioners; 61% were women, 79% were white, and 5% were Hispanic. Physicians had a mean of 29 years since medical school graduation, and one-third planned to retire in 3 to 5 years. Nurse practitioners were earlier in their careers. Respondents reported long wait times for new appointments, clinician burnout, increased patient complexity and up to 50% additional time spent per visit in nonreimbursed clinical-care activities. Female subspecialists spent more time per visit in billable and nonbillable components of clinical care.

CONCLUSIONS

The DBP workforce struggles to meet current service demands, with long waits for appointments, increased complexity, and high volumes of nonreimbursed care. Sex-based practice differences must be considered in future planning. The viability of the DBP subspecialty requires strategies to maintain and expand the workforce, improve clinical efficiency, and prevent burnout.

Does Length of Developmental Behavioral Pediatrics Training Matter?

OBJECTIVE

Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. The objective of this study was to compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP with the practice patterns of those who were trained for <4 weeks.

METHODS

We used self-reported practices from the American Academy of Pediatrics Periodic Survey 85. Pediatricians were asked whether they never, sometimes, or usually inquired about and screened for, and whether they treated/managed/comanaged attention deficit hyperactivity disorder, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates.

RESULTS

Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with attention deficit hyperactivity disorder or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some Diagnostic and Statistical Manual of Mental Disorders criteria and some treatment modalities.

CONCLUSIONS

Longer length of training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.

Preliminary Validation of a Parent-Child Relational Framework for Teaching Developmental Assessment to Pediatric Residents

OBJECTIVE

A parent-child relational framework was used as a method to train pediatric residents in basic knowledge and observation skills for the assessment of child development. Components of the training framework and its preliminary validation as an alternative to milestone-based approaches are described.

METHODS

Pediatric residents were trained during a 4-week clinical rotation to use a semistructured interview and observe parent-child behavior during health visits using clinical criteria for historical information and observed behavior that reflect developmental change in the parent-child relationship. Clinical impressions of concern versus no concern for developmental delay were derived from parent-child relational criteria and the physical examination. A chart review yielded 330 preterm infants evaluated using this methodology at 4 and 15 months corrected age who also had standardized developmental testing at 6 and 18 months corrected age. Sensitivities and specificities were computed to examine the validity of the clinical assessment compared with standardized testing. A subset of residents who completed 50 or more assessments during the rotation was timed at the end of 4 weeks.

RESULTS

Parent-child behavioral markers elicited from the history and/or observed during the health visit correlated highly with standardized developmental assessment. Sensitivities and specificities were 0.72/0.98 and 0.87/0.96 at 4 to 6 and 15 to 18 months, respectively. Residents completed their assessments <1 minute on average if they had completed at least 50 supervised assessments.

CONCLUSIONS

A parent-child relational framework is a potentially efficient and effective approach to training residents in the clinical knowledge and skills of child development assessment.

Improvement of Patient- and Family-Specific Care for Children with Special Behavioral Needs in the Emergency Setting: A Behavioral Needs Education

Improvements in staff training, identification, and treatment planning for children with special health care needs who have behavioral issues are routinely recommended, but a literature review revealed no coherent plans targeted specifically toward pediatric ED staff.

METHODS

An educational module was delivered to emergency staff along with a survey before and after and 1 month after the intervention to examine comfort in working with children with behavioral special needs and the ability to deliver specialized care. Child life consultations in the pediatric emergency department were measured 3 months before and 3 months after the education was provided.

RESULTS

A total of 122 staff participated and reported clinically significant improvements across all areas of care that were maintained at 1 month.

IMPLICATIONS FOR PRACTICE

To the best of our knowledge, this project represents the first quality improvement project offering behavioral needs education to emergency staff at a large pediatric hospital with an examination of its impact on staff competence, comfort, and outcomes. A large-scale educational module is a practical option for improvement in pediatric ED staff competence in caring for patients with behavioral special needs.

The current and ideal state of mental health training: pediatric program director perspectives

OBJECTIVE

To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents' knowledge and skills in MH care.

METHODS

We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics' MH competencies. PDs then ranked their residents' knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence.

RESULTS

Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics competencies, and PDs infrequently rated their residents' MH skills and knowledge to be above average. Attention-deficit/hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P = .04).

CONCLUSIONS

PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents' knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.

Pediatric behavioral health screening in primary care: a preliminary analysis of the pediatric symptom checklist-17 with functional impairment items

BACKGROUND

Roughly 21% of youth in the United States meet criteria for a mental health diagnosis, but only one-fifth of those children obtain help. The Pediatric Behavioral Health Screen (PBHS) utilizes the Pediatric Symptom Checklist-17 (PSC-17) and functional impairment items to assess behavioral health concerns.

METHODS

Data were obtained from a systematic chart review for children 6 to 16 years old. Descriptive analyses and a confirmatory factor analysis were used to evaluate the clinical performance and utility of the PBHS.

RESULTS

A positive screen was endorsed for 26.7% of the sample, of whom 68% also experienced functional impairment. Clinicians appropriately administered the screen 73.5% of the time. The 3-factor model of the PSC-17 exhibited a good model fit.

CONCLUSIONS

Prevalence rates of psychosocial concerns and functional impairment affirm the need for routine behavioral health screening in the pediatric primary care setting. The PBHS exhibited good psychometric performance and clinical utility.

Quality improvement skills for pediatric residents: from lecture to implementation and sustainability

Quality improvement (QI) skills are relevant to efforts to improve the health care system. The Accreditation Council for Graduate Medical Education (ACGME) program requirements call for resident participation in local and institutional QI efforts, and the move to outcomes-based accreditation is resulting in greater focus on the resulting learning and clinical outcomes. Many programs have enhanced practice-based learning and improvement (PBLI) and systems based practice (SBP) curricula, although efforts to actively involve residents in QI activities appear to be lagging. Using information from the extensive experience of Cincinnati Children's Hospital Medical Center, we offer recommendations for how to create meaningful QI experiences for residents meet ACGME requirements and the expectations of the Clinical Learning Environment Review (CLER) process. Resident involvement in QI requires a multipronged approach that overcomes barriers and limitations that have frustrated earlier efforts to move this education from lectures to immersion experiences at the bedside and in the clinic. We present 5 dimensions of effective programs that facilitate active resident participation in improvement work and enhance their QI skills: 1) providing curricula and education models that ground residents in QI principles; 2) ensuring faculty development to prepare physicians for their role in teaching QI and demonstrating it in day-to-day practice; 3) ensuring all residents receive meaningful QI education and practical exposure to improvement projects; 4) overcoming time and other constraints to allow residents to apply their newly developed QI skills; and 5) assessing the effect of exposure to QI on resident competence and project outcomes.

Transition care: future directions in education, health policy, and outcomes research

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined. Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success. In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.

A longitudinal career-focused block for third-year pediatrics residents

BACKGROUND

The traditional 1-month training blocks in pediatrics may fail to provide sufficient exposure to develop the knowledge, skills, and attitudes residents need for practice and may not be conducive to mentoring relationships with faculty and continuity with patients.

INTERVENTION

We created a 4-month career-focused experience (CFE) for third-year residents. The CFE included block time and longitudinal experiences in different content areas related to residents' choice of urban and rural primary care, hospitalist medicine, or subspecialty care (prefellowship). Content was informed by graduate surveys, focus groups with primary care pediatricians and hospitalists, and interviews with fellowship directors. Outcomes were assessed via before and after surveys of residents' attitudes and skills, assessment of skills with an objective structured clinical examination (OSCE), and interviews with residents and mentors.

RESULTS

Twenty-three of 49 third-year residents took part in the first 2 years of CFE. Two residents dropped out, leaving 21 who completed the 4-month experience (9 in primary care, 2 in hospitalist medicine, and 10 in a subspecialty). Residents reported improvement in their clinical skills, increased satisfaction with faculty mentoring and evaluation, and the ability to focus on what was important to their careers. OSCE performance did not differ between residents who completed the CFE and those who did not. Administrative burden was high.

CONCLUSIONS

Four-month career-focused training for pediatrics residents is feasible and may be effective in meeting part of the new requirement for 6 months of career-focused training during pediatrics residency.