Teaching Trainees to Deliver Adolescent Reproductive Health Services

Adolescent medicine training in postgraduate family medicine education: a scoping review

INTRODUCTION

Adolescents and young adults require age-appropriate healthcare services delivered by clinicians with expertise in adolescent medicine. However, resident family physicians report a low perceived self-efficacy and under-preparedness to deliver adolescent medical care. We conducted a scoping review to map the breadth and depth of the current evidence about adolescent medicine training for family medicine residents.

CONTENT

We followed Arksey and O'Malley's framework and searched seven electronic databases and key organizations' webpages from inception to September 2020. Informed by the CanMEDS-FM, we analyzed the extracted data concerning basic document characteristics, competencies and medical topics using numerical and qualitative content analysis.

SUMMARY

We included 41 peer-reviewed articles and six adolescent health competency frameworks (n=47). Most competencies taught in family medicine programs were organized under the roles of family medicine expert (75%), communicator (11.8%), and professional roles (7.9%). Health advocate and leader were rarely included (1.3%), and never scholar.

OUTLOOK

The omission of multiple competency roles in family medicine resident education on adolescents is insufficient for family physicians to deliver optimal care to adolescents. The combined efforts of family medicine stakeholders to address adolescent medicine competency gaps may positively impact the perceived competence reported by family medicine residents.

Identifying a Knowledge Deficit among Pediatric and General Practitioner Trainees in Pediatric and Adolescent Gynecology in an Irish Hospital: A Pilot Study

STUDY OBJECTIVE

We aim to show that there is a knowledge deficit among pediatric and general practitioner (GP) trainees in pediatric and adolescent gynecology (PAG) and that this has implications for increased morbidity in girls. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: In October 2019 in a tertiary Irish pediatric hospital 50 junior doctors were approached (of a possible 66) and were surveyed in their knowledge of PAG with a written 21-question questionnaire incorporating 10 topics.

RESULTS

Forty candidates participated (n = 31 pediatric and 9 GP). Sixty percent (n = 24/40) incorrectly misdiagnosed vulvovaginitis as candida; 80% (n = 32/40) could not identify labial adhesions; 47.5% (n = 19/40) were unable to define heavy menstrual bleeding. All of the GP trainees (n = 9/9) said they would prescribe the oral contraceptive pill compared with 51.6% (n = 16/31) of pediatric trainees; 52.5% (n = 21/40) did not consider sexually transmitted infection screening; and 70% (n = 28/40) could not identify female genital mutilation. There was generally no statistically significant difference between GP and pediatric trainees.

CONCLUSION

A knowledge deficit among trainees was evident in relation to PAG from common to rare, but serious PAG conditions. Misdiagnosis and delayed treatment could lead to increased morbidity for girls. We recommend the introduction of a standardized training program in PAG for trainees.

Perceptions Regarding Pediatric and Adolescent Gynecology Training among Obstetrics and Gynecology Residents in Hawai'i

A pediatric and adolescent gynecology curriculum was implemented for obstetrics/gynecology residents at a single institution in Hawai'i. The primary objective of this study was to evaluate the effectiveness of this pediatric and adolescent gynecology (PAG) formal curriculum in improving knowledge. Twelve residents at the University of Hawai'i completed the curriculum during their second year of training. Of these, 6 residents completed an examination assessing knowledge both before and immediately after the curriculum. Five of these residents completed the examination 1-2 years after completing the curriculum. Average pre-rotation examination scores were 57%, which increased significantly immediately after the curriculum to 87% (P=.003) and remained significantly higher after 1-2 years with average scores of 71% (P=.025). A secondary objective was to assess resident comfort and confidence levels in the subject. All residents who completed the curriculum completed surveys assessing comfort in their pediatric and adolescent gynecology training and both perceived confidence and competence in this area. Despite completing the curriculum, 7 of 12 (58%) did not feel comfortable evaluating pediatric gynecology patients, and 5 of 12 (42%) did not feel prepared nor competent to care for pediatric and adolescent patients. A formal pediatric and adolescent gynecology curriculum increased examination performance, which suggests knowledge retention. However, despite curriculum completion, residents still desired more training in the subject area. Residency programs should consider innovative ways to incorporate inpatient and outpatient educational experiences, periodic testing, and feedback longitudinally throughout residency training to improve long-term retention, confidence, and competence in providing gynecologic care in the pediatric and adolescent gynecology population.

Effectiveness of the Adolescent Medicine Rotation in Improving Pediatric Residents Self-Assessed Skill and Confidence Caring for Youth

PURPOSE

Practicing and resident pediatricians report inadequate skill in caring for adolescents, despite adolescents comprising roughly one-quarter of most general and subspecialty practices. This study examined the effectiveness of participation in an adolescent medicine rotation at improving pediatric residents' self-perceived skills and confidence across nine key adolescent health domains. We also evaluated the impact of didactic instruction during the rotation.

METHODS

Resident and recent-graduate participants (n = 34) completed milestone-based self-assessment of their skill and confidence caring for adolescent patients in nine key adolescent health-related domains. This study employed a post-test then retrospective pretest, an educational study design used to minimize response-shift bias whereby participants rate their skill and confidence at the end of the intervention (post-test), and then reflect back to retrospectively rate their preintervention skill (retrospective pretest). Additionally, differences in gains between those who did and did not participate in didactic instruction were evaluated. Didactic instruction was delivered during the adolescent medicine rotation utilizing a flipped-classroom model; participants received standardized preparatory materials and participated in active-learning workshops.

RESULTS

Participants demonstrated a significant (p ≤ .0001) increase in self-perceived skill levels for all assessed domains after the rotation as compared to before the rotation, whether or not they received didactic instruction. Participation in didactic instruction did not yield significant (p ≤ .05) additional benefit for any of the assessed domains.

CONCLUSIONS

Participation in an adolescent medicine rotation is of value to pediatric resident trainees and leads to increased self-assessed skill and confidence in caring for youth.

Characteristics Associated with Confidential Consultation for Adolescents in Primary Care

OBJECTIVE

To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training.

STUDY DESIGN

This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent-reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ² tests. Associations between adolescent characteristics, risk factors, and provider-reported confidential consultation were examined using logistic regression analyses.

RESULTS

The sample included 1233 English and Spanish-speaking adolescents 12-20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation.

CONCLUSIONS

Provider training is needed to reinforce the importance of confidential consultation for all adolescents.

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.