The training of pediatric residents in the care of acutely ill and injured children

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.     

Management of febrile infants and children by pediatric emergency medicine and emergency medicine: comparison with practice guidelines

OBJECTIVES: Management of febrile infants and children remains controversial despite the 1993 publication in Pediatrics and Annals of Emergency Medicine of practice guidelines. Our aim was to determine the management of febrile infants and children by pediatric emergency medicine (PEM) fellowship directors and emergency medicine (EM) residency directors and compare their approach with the published practice guidelines. METHODS: Four case scenarios were sent to 64 PEM directors and 100 EM directors in the United States and Canada, describing four febrile, nontoxic infants and children aged 25 days (case 1), 7 weeks (case 2), 5 months (case 3), and 22 months (case 4). Respondents were asked to select which laboratory tests and radiographs they would obtain and to decide on treatment and disposition for each hypothetical case. RESULTS: Ninety-two percent (53/64) of PEM directors and 64% (64/100) of EM directors responded (overall response rate 74%). Compliance with the guidelines (PEM/EM) was 54%/16% for case 1, 31%/6% for case 2, 35%/19% for case 3, and 20%/11% for case 4. Only 11% of PEM and 2% of EM directors followed the guidelines for all four cases. Overall, directors performed fewer laboratory tests, ordered more chest radiographs and treated fewer patients with antibiotics than the expert panel suggested. EM directors ordered more chest radiographs (cases 1-4) and admitted more patients (case 2) than PEM directors. CONCLUSIONS: There is poor compliance with published practice guidelines in the management of febrile infants and children among PEM and EM directors.     

Breastfeeding education and support services offered to pediatric residents in the US

ObjectiveThe American Academy of Pediatrics (AAP) encourages pediatricians to support the practice of breastfeeding and residency educators to develop formal curricula in breastfeeding education. Few studies, however, describe breastfeeding education or support services currently provided to pediatric residents in the United States. The goals of this study were to investigate breastfeeding training offered during 3-year pediatric residency programs and to describe residency programs’ policies and services for residents who breastfeed.MethodsWe conducted a cross-sectional study using a Web-based survey of pediatric program directors regarding breastfeeding education and support services for residents.ResultsSeventy percent of program directors (132 of 189) completed the survey, with 77.3% of respondents (n = 102) estimating the amount of breastfeeding education offered to their pediatric residents. Residents are provided with a median total of 9.0 hours of breastfeeding training over 3 years, primarily in continuity clinic and in lectures and rounds with attendings. At the programs’ primary teaching hospitals, breastfeeding residents are provided breastfeeding rooms (67.0%), breast pumps (75.3%), and breast milk storage facilities (87.6%). Only 10 programs reported having an official policy to accommodate breastfeeding residents.ConclusionsPediatric residents receive approximately 3 hours of breastfeeding training per year. In addition, there is less than universal implementation by residency programs of AAP recommendations for supporting breastfeeding in the workplace. Pediatric residency programs should find ways to improve and assess the quality of breastfeeding education and workplace support to better role model this advocacy standard.     

Community pediatrics: a consistent focus in residency training from 2002 to 2005.

OBJECTIVE: To assess changes in community pediatrics training from 2002 to 2005. METHODS: Pediatric residency program directors were surveyed in 2002 and 2005 to assess resident training experiences in community pediatrics. Program directors reported on the following: provision of training in community settings; inclusion of didactic and practical teaching on community health topics; resident involvement in legislative, advocacy, and community-based research activities; and emphasis placed on specific resources and training during resident recruitment. Cross-sectional and matched-pair analyses were conducted. RESULTS: A total of 168 program directors participated in 2002 (81% response rate), and 161 participated in 2005 (79% response rate). In both years, more than 50% of programs required resident involvement with schools, child care centers, and child protection teams. Compared with 2002, in 2005, more programs included didactic training on legislative advocacy (69% vs 53%, P < .01) and offered a practical experience in this area (53% vs 40%, P < .05). In 2005, program directors reported greater resident involvement in providing legislative testimony (P < .05), and greater emphasis was placed on child advocacy training during resident recruitment (P < .01). CONCLUSIONS: In the last several years, there has been a consistent focus on legislative activities and child advocacy in pediatric residency programs. These findings suggest a strong perceived value of these activities and should inform efforts to rethink the content of general pediatric residency training in the future.     

Removing the pediatric cervical collar: current practice patterns

OBJECTIVES: To identify the current practice patterns of emergency medicine practitioners and the typical criteria used in discontinuing cervical spine immobilization (CSI) in the pediatric patient. DESIGN: Mail-in survey. PARTICIPANTS: All physicians on the mailing list of the American Academy of Pediatrics Section of Emergency Medicine and an equal number of randomly chosen members of the American College of Emergency Physicians. The total number of participants was 1360. METHODS: The survey consisted of a case scenario describing a 3-year-old child brought to the emergency department with CSI. The approach to such a scenario was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat mailings were sent at 4 and 8 weeks after the first mailing. Those not currently in active practice or not involved in the decision to discontinue CSI were excluded from the study. RESULTS: The response rate was 55%. Most respondents were younger than 44 years (71%), in practice less than 10 years (56%), and practiced in an urban setting (68%). Nearly two thirds (62.6%) had completed residency training in pediatrics, 24% in emergency medicine and 36% a pediatric emergency medicine fellowship. Most (63%) would discontinue CSI without obtaining radiographs. Factors associated with removal were residency training in pediatrics and being in practice for less than 10 years. The most common criteria for discontinuing CSI were normal neurological (96%) and cervical spine (98%) examinations, normal mental status (92%), and absence of neck pain (93%). CONCLUSIONS: Discontinuing CSI without obtaining radiographs is common, especially among those with residency training in pediatrics and those in practice for less than 10 years. Knowledge of current practice is essential to future development of guidelines for managing pediatric trauma patients for whom cervical spine injury is a consideration.     

Occult bacteremia in children with simple febrile seizures

The controversy surrounding the diagnostic workup for simple febrile seizures has centered around the lumbar puncture. This focus has obscured the potential importance of other tests. A retrospective study was performed to determine the frequency of occult bacteremia in simple febrile seizures. In a pediatric emergency department, we identified 115 cases of simple febrile seizures in children treated as outpatients. Blood cultures were performed in 93 (81%) of 115 patients; five (5.4%) were positive. Children were less likely to have blood cultures performed if they were older than 24 months or had a medical history of simple febrile seizures. However, neither age nor history of febrile seizures affected the risk of bacteremia. These data suggest that patients with simple febrile seizures are at approximately the same risk for bacteremia as children with fever alone. Patients with simple febrile seizures should be treated in the same manner as other patients of the same age with regard to the performance of blood cultures.     

Pediatric Resident Training in the Community Hospital Setting: A Survey of Program Directors

Background and ObjectiveThe role of a hospitalist differs in a community hospital (CH) compared to a university/children's hospital. Residents are required to practice in a variety of relevant clinical settings, but little is known about current trends regarding pediatric resident training in different hospital settings. This study explores CH rotations including their value for resident training, characteristics, benefits, and drawbacks. This study also seeks to define “community hospital.”MethodsAuthors conducted an online cross-sectional survey of pediatric residency program directors distributed by the Association of Pediatric Program Directors. The survey was developed and revised based on review of the literature and iterative input from experts in pediatric resident training and CH medicine. It assessed residency program demographics, availability of CH rotations, value of CH rotations, and their characteristics including benefits and drawbacks.ResultsResponse rate was 56%. CH rotations were required at 24% of residency programs, available as an elective at 46% of programs, and unavailable at 48% of programs. Residency program directors viewed these rotations as valuable for resident training. CH rotations were found to have multiple benefits and drawbacks. Definitions of “community hospital” varied and can be categorized according to positive or negative characteristics.ConclusionsResident rotations at a CH provide valuable learning opportunities with multiple potential benefits that should be weighed against drawbacks in the context of a residency program's curriculum. There are many characteristics that potentially distinguish CH from university/children's hospitals.     

Look Who's Talking: A Survey of Pediatric Program Directors on Communication Skills Education in Pediatric Residency Programs

ObjectiveTo determine current practices for communication skills curriculum and assessment in pediatric residency programs and to identify programs’ greatest needs regarding communication curricula and assessment.MethodsWe surveyed pediatric residency program directors about their programs’ approach to teaching and assessing residents’ communication skills and how satisfied they were with their curricula and assessment of competence. Respondents were asked about their programs’ greatest needs for teaching and assessing communication skills.ResultsResponse rate was 41% (82/202). Most programs did teach communication skills to residents; only 14% provided no formal training. Programs identified various 1) educational formats for teaching communication skills, 2) curricular content, and 3) assessment methods for determining competence. Many programs were less than satisfied with their curriculum and the accuracy of their assessments. The greatest programmatic need regarding curricula was time, while the greatest need for assessment was a tool.ConclusionsWhile teaching and assessment of communication skills is common in pediatric residency programs, it is inconsistent and variable, and many programs are not satisfied with their current communication training. There is need for development of and access to appropriate and useful curricula as well as a practical tool for assessment which has been evaluated for validity evidence.     

Training in community pediatrics: a national survey of program directors.

OBJECTIVE: To describe the spectrum of residency training in community-based settings, assess the extent of resident education on community pediatrics topics, and determine whether educational activities vary by program size or availability of primary care tracks. METHODS: Survey of US pediatric residency program directors from May-September 2002. A 10-item self-administered questionnaire assessed the programs' extent of resident involvement in 15 selected community-based settings and inclusion of didactic or practical education regarding 13 community health topics. RESULTS: Of 168 programs surveyed (81% response rate), 40% were small (< or =30 residents), 35% were medium (31-50 residents), 25% were large (>50 residents), and 15% had primary care tracks. Frequently required community-based settings included schools (69%), child protection teams (62%), day care centers (57%), and home visiting (48%). Of 15 community-based settings, 28% required involvement in fewer than 4, 41% required involvement in 4-6, and 31% required involvement in 7 or more. More than two-thirds offered didactic teaching and practical experience on issues related to managed care, cultural competency, and the mental health and social service systems. There were no differences in the number of required community-based settings by program size or presence of primary care tracks. CONCLUSIONS: Most pediatric residency programs require exposure to community-based settings and provide education on various community health topics. Ongoing challenges include continued implementation amid work duty hour limitations, best practice models for practical implementation of community-based experience into residency training, and the impact of such training on future involvement in the community and physician practice.     

Response to child abuse in the pediatric emergency department: need for continued education

BACKGROUND: Child abuse is a leading pediatric public health problem. Pediatric emergency physicians are on the front line to identify and respond to child abuse. The physician's response to suspected child abuse cases is influenced by educational content and experience. OBJECTIVE: To determine pediatric emergency medicine Fellows' level of preparedness to respond to suspected child abuse, and to assess obstacles and attitudinal barriers to effective response. STUDY DESIGN: Self-reported written survey. METHODS: A 30-item anonymous questionnaire was mailed to 162 pediatric emergency medicine Fellows in the United States and Canada in 1995. A response rate of 77.2% (n = 125) was achieved. RESULTS: Prior to fellowship, 97.6 % of the responding Fellows reported having had some pre-fellowship instruction, including formal courses, conferences, and direct patient contact, on child abuse during medical school and residency. Whereas the majority (61.4%) received > or =10 hours of child abuse response instruction before fellowship, most (70.1 %) reported <10 hours of child abuse response instruction during their fellowship; 17.1 % reported they had no child abuse response training during their fellowship. Prior experience was also determined by reported involvement with managing child abuse cases during their medical training to date. Before fellowship, the median level of child abuse case involvement was 15 (mode 20) compared with a median of 10 cases (mode 10) reported during fellowship training. More than one third (48/125) noted the lack of organized lectures or conferences on child abuse available during fellowship training. While the majority (107/125) reported the opportunity to do a rotation in child protection/ abuse during fellowship training; the rotation was required for only 32.7% (35/107); among Fellows who reported an elective rotation in child abuse (72/107), one half (36/72) reported that they were unlikely to participate. Factors most frequently selected as perceived obstacles to responding to child abuse included lack of formal training on the topic (33.6%), lack of experience handling these cases (37.6%), personal discomfort (41.6%), and perceived lack of response by local protective services (42.4%) and police (25.6%). Sixty percent (75/125) had a protocol in the pediatric emergency department to facilitate response to child abuse. Many felt ill-prepared to interact with Child Protective Services (52.8%) and police (42.4 %). Prior experience managing child abuse cases and educational content during fellowship training were independently predictive of frequency of identifying cases of child abuse during fellowship. CONCLUSIONS: Significant training gaps in postgraduate medical education on response to child abuse for the pediatric emergency subspecialist are identified, as well as perceived obstacles to effective response, which may have implications for designing future curricula.     

Management of febrile children in the conjugate pneumococcal vaccine era

The objective of this study was to evaluate physician attitudes toward the management of young febrile children since the introduction of the conjugate heptavalent pneumococcal vaccine (PCV 7). Seven thousand five hundred pediatricians and 7,500 emergency department (ED) physicians were surveyed with regard to their management of a febrile 7-month-old child and 20-month-old child without an apparent fever focus. Specifically, physicians were asked how they would manage a febrile child who had and who had not been vaccinated with PCV 7. When evaluating a febrile 7-month-old child, pediatricians would order 5% fewer complete blood cell (CBC) counts and 6% fewer blood cultures (p<0.0001) if a child was vaccinated. ED physicians would order 13% fewer CBC's and 15% fewer blood cultures (p<0.0001). ED physicians and pediatricians ordered fewer chest radiographs, an 8% and 3% decrease, respectively (p<0.0001). For the PCV 7 immunized 20-month-old child, pediatricians ordered 6% fewer CBC counts and 8% fewer blood cultures (p<0.0001). ED physicians would perform 12% fewer CBC counts and cultures (p<0.0001). Four percent fewer pediatricians and 10% fewer ED physicians would order chest radiographs (p<0.0001). When treating the vaccinated 7-month-old child, pediatricians would use 11% less ceftriaxone and ED physicians 20% less (p<0.0001). Twelve percent fewer pediatricians and 19% fewer ED physicians would administer ceftriaxone (p<0.0001) for the 20-month-old vaccinated child. Our survey suggests that pediatricians and ED physicians would order fewer CBC counts and blood cultures and administer less empiric ceftriaxone if a child was vaccinated with PCV 7.     

The pediatric program director. An analysis of the role and its problems

A questionnaire designed to elicit information about the work environment, knowledge, and stresses of pediatric residency program directors was mailed to the 235 member programs of the Association of Pediatric Program Directors (APPD). At the time that the 187 respondents (80% return rate) assumed responsibility for their training programs, many rated their knowledge of various aspects of residency program administration as "poor." The respondents indicated that a lack of time, the pressures of too many other academic responsibilities, and a fear of not "filling" all positions in the National Intern Matching Program created much personal stress. Most program directors felt that educational conferences designed to teach educational methods, and administrative skills, and provide technical information knowledge necessary for residency program supervision would be beneficial.     

Pediatric Emergency Medicine Fellowship survey: 1991-1992.

This study was designed to determine the general characteristics, training expectations, and career goals of those individuals entering Pediatric Emergency Medicine Fellowships in 1992 through the NRMP Pediatric Emergency Medicine Match. A 20-item questionnaire was developed and sent to those individuals who successfully obtained fellowship positions through the 1991-1992 Match. All of the respondents will have completed a formal pediatric residency program, and 90% will have completed their residency since 1990. Eighty-eight percent of the respondents have not completed formal postgraduate training other than a pediatric residency, and none of the respondents were from training programs in emergency medicine. Ninety percent of the respondents are planning on two years of training, while 10% are either entering a three-year program or planning an optional third year. Ninety-four percent of the individuals who responded had not applied for Pediatric Emergency Medicine Fellowships in the past, but, while many of the individuals were concerned about obtaining a position, only 6% applied for a fellowship in an alternative field. If the respondents had not obtained positions this year, 79% felt that they would have reapplied next year. When asked why they are pursuing a Pediatric Emergency Medicine Fellowship, 85% listed opportunities in clinical medicine as their primary reason, while 10% claimed that research opportunity was the most important factor. When their fellowships are completed, 77% hope to practice at a university-based children's hospital, and 10% hope to practice at a private children's hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

How and how well do pediatric radiology fellows learn ultrasound skills? A national survey

Background

Ultrasound (US) comprises a significant portion of pediatric imaging. Technical as well as interpretive skills in US imaging are consequently fundamental in training pediatric radiologists. Unfortunately, formalized technical education regarding US imaging in pediatric fellowships has lagged.

Objective

We surveyed pediatric fellows and program directors regarding US scanning education to improve this experience moving forward.

Materials and methods

We conducted an online survey from February 2011 to March 2011 of all United States pediatric radiology body imaging fellows and fellowship program directors. Questions posed to fellows assessed their educational US experiences during their residencies and fellowships. Directors were asked to evaluate US educational opportunities in their programs.

Results

Among the respondents, 43.9% of fellows undertook on-call US scanning without a sonographer during residency, 23.3% during fellowship; 41.8% of fellows and 58.6% of program directors reported that their fellowship had a dedicated curriculum to facilitate independent US scanning. Both fellows and program directors cited the volume of cases requiring immediate dictation as an obstacle to scanning. Fewer program directors than fellows identified lack of sufficient staffing as an obstacle, but more identified fellow disinterest. Program directors and fellows alike rated independent US scanning as highly important to pediatric radiologists’ future success.

Conclusion

Pediatric radiology fellowship directors and fellows agree that technical US skills are crucial to the practice of pediatric radiology. However, the groups identify different obstacles to training. As US instruction is developing in undergraduate medicine and subspecialists are acquiring point-of-care US skills, pediatric radiology education should address the obstacles to US training and formalize a curriculum at the fellowship level.     

Pain relief for neonatal circumcision: a follow-up of residency training practices.

OBJECTIVE: To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision. METHODS: All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940). RESULTS: Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%. CONCLUSIONS: The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.     

Approach to the child with prolonged fever in the pediatric emergency department

Children with prolonged fever represent diagnostic challenges. Although prolonged fever has been variously defined, the most widely accepted definition of fever of unknown origin in a child is an unexplained febrile illness lasting at least 8 days. Other term, fever without localizing signs, and fever without source refer to children with fever of shorter duration, generally less than 5 days. This review focuses on children with fever greater than 5 days duration. In each case, the practitioner of pediatric emergency medicine must be systematic and highly organized. He or she must first carefully review the child's history and physical examination for overlooked clinical clues, and then must make use of a focused set of laboratory and radiological tests. A “shotgun” approach must be avoided. Hospital admission may occasionally be warranted for die extremely ill child or to facilitate further evaluation, Extensive family counseling and close clinical follow-up are crucial. Repetition of the history and physical examination, is well is serial careful observations, may yield important leads that less rigorous physicians failed to see. Compared with adults, children have fewer life-threatening and chronic conditions that present as prolonged fever. Occult infections acocunt for nearly 50% of cases anti the overall mortality is low.     

Parental fever phobia and its correlates

Parents of 202 young febrile children were surveyed about their knowledge, attitudes, and fears concerning fever and its treatment. Forty-eight percent of the parents considered temperatures less than 38.0 degrees C to be "fevers", 43% felt that temperatures less than 40.0 degrees C could be dangerous to a child, 21% favored treatment for fevers less than 38.0 degrees C, and 15% believed that, left untreated, temperature could rise to 42.0 degrees C or higher. Fifty-three percent advocated waking a febrile child at night to administer antipyretic therapy. Young age of the child was associated with a preference for use of acetaminophen over aspirin and, unexpectedly, with a higher parental threshold for consideration of fever. The higher their child's temperature at the time they were questioned, the higher the minimum temperature that parents considered a cause for concern. Surprisingly, higher socioeconomic status was not associated with a lesser degree of fever phobia. In fact, parents of higher socioeconomic status were more concerned about the risks of brain damage or seizures as sequelae of fever than were parents of lower socioeconomic status. It is concluded that undue fear and overly aggressive treatment of fever are epidemic among parents of infants and young children, even among the highly educated and well-to-do. Considerable effort will be required on the part of pediatricians and other child health workers to reeducate these parents about the definition, consequences, and appropriate treatment of fever.     

Parent perceptions of the specialty pediatric emergency medicine and their understanding of the provider roles in a Pediatric Emergency Department

This study was conducted to assess parents' understanding of Pediatric Emergency Medicine and the roles of different providers in a pediatric emergency department. Parents were surveyed regarding these subjects and given a sheet explaining provider roles. Of 102 questionnaires completed, 82% of questions on attending roles were answered correctly and 70% of questions about pediatric emergency medicine were answered correctly. Ninety percent of parents felt the information sheet made understanding provider roles easier. Many parents were informed regarding emergency department provider roles. Certain aspects of these roles and the practice of pediatric emergency department are less well understood. An informational sheet can help educate parents about provider roles and the practice of pediatric emergency medicine.     

The occult bacteremia controversy

A young child with a high fever and no source for infection is a common situation confronting pediatricians and pediatric emergency medicine physicians alike. Although most febrile children with no apparent source of infection are suffering from viral illnesses, a percentage will he harboring occult bacterial infection. Whereas most cases of occult bacteremia resolve spontaneously, a small number of cases progress to serious bacterial illness, This article reviews the approach to children 3 to 36 months of age with fever mid no apparent source and reflects on practice guidelines developed to guide clinicians managing this situation, The rationale for a variety of management approaches is reviewed and data from ongoing studies which might influence care in the future are presented.