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Di Rocco JR, Kimata C, Barat M, Kodama S. Paediatric resident workflow observations in a community-based hospital. BMJ Open Qual 2022; 11:bmjoq-2021-001607. [PMID: 35241437 PMCID: PMC8896048 DOI: 10.1136/bmjoq-2021-001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 02/20/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital. Methods One of three trained observers followed a resident physician during a convenience sample of 1–2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs. Results 18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident’s attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents’ MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11). Conclusions Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.
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Affiliation(s)
- Jennifer R Di Rocco
- Pediatrics, Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii, USA .,Pediatrics, University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Chieko Kimata
- Patient Safety & Quality Services, Hawai'i Pacific Health, Honolulu, Hawaii, USA
| | - Masihullah Barat
- University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Samantha Kodama
- University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
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2
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Abstract
Burnout is highly prevalent among physicians and is associated with negative patient outcomes. Furthermore, medical training is a particularly vulnerable time as studies show that medical students, residents, and fellows experience burnout and emotional exhaustion at higher rates than both the general population and physicians in practice. Multiple recent studies have demonstrated the practice of religion and spirituality to be protective against burnout in trainees. Can Catholic academic physicians transfer these protective benefits of religion and spirituality to their trainees, who are at the highest risk, and who may or may not share their faith? An ancient Catholic tradition, the Seven Spiritual Works of Mercy, may hold the key. The Spiritual Works of Mercy are listed by the US Conference of Catholic Bishops as Counseling the Doubtful, Instructing the Ignorant, Admonishing the Sinner, Comforting the Sorrowful, Forgiving Injuries, Bearing Wrongs Patiently, and Praying for the Living and the Dead. Using this as a framework, examples of evidenced-based actions from the literature that have been shown to either prevent burnout or to improve the day-to-day experience of medical trainees were discussed. Examples include encouraging trainees to express doubts or to debrief after difficult and saddening cases. Academic physicians can provide instruction, feedback, or admonishment; demonstrate forgiveness of errors; and model the way in bearing wrongs patiently, all while uplifting their trainees in prayer. The Spiritual Works of Mercy can thus become a framework for academic physicians to uplift their trainees' spirits and potentially prevent against burnout. Summary Burnout is highly prevalent in medical students and in doctors during their residency or fellowship training, but multiple studies have shown regular practice of religion and spirituality to be protective against burnout. The Seven Spiritual Works of Mercy (Counsel the Doubtful, Instruct the Ignorant, Admonish the Sinner, Comfort the Sorrowful, Forgive All Injuries, Bear Wrongs Patiently and Pray for the Living and the Dead) provide a framework of powerful examples for teaching physicians, particularly Catholic teaching physicians, to uplift their students and potentially transfer this benefit to reduce their students' risk for burnout.
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Affiliation(s)
- Paul M Shaniuk
- Louis Stokes Cleveland Veterans Affairs Medical Center, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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3
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Abstract
Resident and attending concern about the potential for decreased teaching has been cited as one of the drawbacks to the adoption of family-centered rounds (FCR). Despite these concerns, FCR can enhance clinical education through direct exposure to multiple patients by all team members, as well as by allowing faculty to teach, model, observe, and assess learners' clinical skills more effectively than in nonbedside settings. This article provides many strategies and approaches to bedside teaching designed to enhance education and communication among care team members as well as patients and their families.
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Affiliation(s)
- Thuy L Ngo
- Pediatric Emergency Medicine, Johns Hopkins School of Medicine, 1800 Orleans Street, G-1509, Baltimore, MD 21287, USA.
| | - Rebecca Blankenburg
- Pediatric Hospital Medicine, Stanford School of Medicine, 725 Welch Road, MC 5906, Palo Alto, CA 94304, USA
| | - Clifton E Yu
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
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4
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Gali HE, Baxter SL, Lander L, Huang AE, Millen M, El-Kareh R, Nudleman E, Chao DL, Robbins SL, Heichel CWD, Camp AS, Korn BS, Lee JE, Kikkawa DO, Longhurst CA, Chiang MF, Hribar MR, Ohno-Machado L. Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures. J Acad Ophthalmol 2019; 11:e65-e72. [PMID: 33954272 DOI: 10.1055/s-0039-3401986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation. Design Prospective, manual time-motion observations of ophthalmology trainees in 2018. Participants Eleven ophthalmology residents and fellows observed during 156 patient encounters. Methods Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models. Main Outcome Measures Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients. Results Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011). Conclusion Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.
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Affiliation(s)
- Helena E Gali
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California.,UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Sally L Baxter
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California.,UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Lina Lander
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Abigail E Huang
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Marlene Millen
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Robert El-Kareh
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Eric Nudleman
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Daniel L Chao
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Shira L Robbins
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Christopher W D Heichel
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Andrew S Camp
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Bobby S Korn
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Jeffrey E Lee
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Don O Kikkawa
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Christopher A Longhurst
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Michael F Chiang
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.,Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.,Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Lucila Ohno-Machado
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California.,Division of Health Services Research and Development, Veterans Administration San Diego Healthcare System, La Jolla, California
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5
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Starmer AJ, Schnock KO, Lyons A, Hehn RS, Graham DA, Keohane C, Landrigan CP. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf 2017; 26:949-957. [DOI: 10.1136/bmjqs-2016-006224] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 11/04/2022]
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6
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Martínez González C, Tasso Cereceda M, Sánchez Jacob M, Riaño Galán I. Solid paediatricians in liquid times: Reviving professionalism. Anales de Pediatría (English Edition) 2017. [DOI: 10.1016/j.anpede.2016.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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7
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Martínez González C, Tasso Cereceda M, Sánchez Jacob M, Riaño Galán I. Pediatras sólidos en tiempos líquidos. Reanimando la profesionalidad. An Pediatr (Barc) 2017; 86:354.e1-4. [DOI: 10.1016/j.anpedi.2016.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/11/2016] [Indexed: 11/19/2022] Open
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8
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Destino LA, Valentine M, Sheikhi FH, Starmer AJ, Landrigan CP, Sanders L. Inpatient Hospital Factors and Resident Time With Patients and Families. Pediatrics 2017; 139:peds.2016-3011. [PMID: 28557735 DOI: 10.1542/peds.2016-3011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care. METHODS We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ≥12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital. RESULTS Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ≥12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05). CONCLUSIONS On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.
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Affiliation(s)
| | | | | | - Amy J Starmer
- Division of General Pediatrics, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Sleep Medicine and.,Center for Patient Safety Research and Practice, Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Lee Sanders
- General Pediatrics, Department of Pediatrics, School of Medicine and.,Center for Health Policy, Primary Care Outcomes Research Center, Stanford, California
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9
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Campbell JK, Ortiz MV, Ottolini MC, Birch S, Agrawal D. Personal Digital Assistant-Based Self-Work Sampling Study of Pediatric Interns Quantifies Workday and Educational Value. Acad Pediatr 2017; 17:288-295. [PMID: 27965068 DOI: 10.1016/j.acap.2016.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 11/23/2016] [Accepted: 12/03/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Optimizing clinical proficiency and education of residents has become more important with restricted residency duty hours. Our objective was to investigate how interns spend their time on inpatient rotations and the perceived educational value of workday activities. METHODS We performed a descriptive self-work sampling study using a personal digital assistant (PDA) to randomly query interns on inpatient rotations in real time regarding their activity and the perceived educational value of that activity on a 4-point Likert scale. RESULTS A total of 31 interns participated on 88 workdays over a 5-month period, generating 2082 samples from which the average workday was modeled. Time spent using the electronic health record (EHR) accounted for 33% of intern time, communicating with the health care team 23%, educational activities 17%, and time with patients and families 12%. Time with patients and families was perceived to be the most educational part of clinical service. Time spent using the EHR was perceived as the least educational. Interns perceived clinical service as excellent or good 37% of the time, while planned educational activities were perceived as excellent or good 81% of the time. CONCLUSIONS Interns spend the majority of their time using the EHR and communicating with the health care team. Interns perceive time spent in planned educational activities has more educational value than time spent in clinical service. The distribution of daily activities is discordant with the perceived educational value of those activities.
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Affiliation(s)
| | | | | | - Sarah Birch
- Children's National Medical Center, Washington, DC
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10
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Seltz LB, Preloger E, Hanson JL, Lane L. Ward Rounds With or Without an Attending Physician: How Interns Learn Most Successfully. Acad Pediatr 2016; 16:638-44. [PMID: 27283038 DOI: 10.1016/j.acap.2016.05.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/24/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore pediatric interns' perspectives on the educational value of general pediatric ward rounds, in particular their rounding experiences with and without an attending physician. METHODS Qualitative study using individual interviews of pediatric interns (2013-2014) rotating on 2 general pediatric inpatient services at different institutions with different rounding team structures. In accordance with grounded theory methodology, data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into themes. RESULTS Twenty pediatric interns participated in 25 interviews. Data analysis yielded 4 themes: what is being learned; learning environment on rounds; learning and work; and ways of learning. Senior residents generally taught practical aspects of patient care and attending physicians taught broader concepts with references to the medical literature. Rounds without an attending physician were perceived as less formal and promoted collaborative discussions with senior residents. Interns were more uncomfortable during rounds with an attending physician but appreciated how that facilitated their learning. Although patient care tasks provided opportunities for experiential learning, interns frequently perceived them to impede learning during rounds. Intern learning during ward rounds occurred via self-directed learning, interactive learning, and through caring for patients. Brief, clinically relevant teaching pearls and questioning clinical reasoning in a respectful manner were helpful. CONCLUSIONS Interns learn different content and learn in different ways depending on the presence or absence of an attending physician at rounds. There might be educational value from rounding with teams that include and do not include an attending physician.
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Affiliation(s)
- L Barry Seltz
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo.
| | - Erin Preloger
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Janice L Hanson
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Lindsey Lane
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
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Abstract
BACKGROUND Research on resident workloads has focused primarily on the quantity of hours worked, rather than the content of those hours or the variability among residents. We hypothesize that there are statistically significant variations in resident workloads and better understanding of workload intensity could improve resident education. METHODS The Stanford Children's Health research database was queried for all electronic notes and orders written by pediatric residents from June 2012 to March 2014. The dataset was narrowed to ensure an accurate comparison among residents. A survey was used to determine residents' self-perceived workload intensity. Variability of total notes written and orders entered was analyzed by χ(2) test and a Monte Carlo simulation. Linear regression was used to analyze the correlation between note-writing and order-entry workload intensity. RESULTS A total of 20 280 notes and 112 214 orders were written by 26 pediatric interns during 6 core rotations between June 2012 and June 2013. Both order-entry and note-writing workload intensity showed highly significant (P < .001) variability among residents. "High workload" residents, defined as the top quartile of total workload intensity, wrote 91% more orders and 19% more notes than "low workload" residents in the bottom quartile. Statistically significant correlation was observed between note-writing and order-entry workload intensity (R(2) = 0.22; P = .02). There was no significant correlation between residents' self-perceived workload intensity and their objective workload. CONCLUSIONS Significant variations in workload exist among pediatric residents. This may contribute to heterogeneous educational opportunities, physician wellness, and quality of patient care.
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Affiliation(s)
| | | | - K T Park
- Department of Pediatrics, and Gastroenterology, Stanford University School of Medicine, Palo Alto, California
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12
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Lin JA. Stone Throwing in the Glass House. Front Pediatr 2016; 4:20. [PMID: 27014670 PMCID: PMC4789799 DOI: 10.3389/fped.2016.00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/29/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- James Anthony Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital UCLA, University of California Los Angeles , Los Angeles, CA , USA
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