The most difficult clinical situations: a survey of Victorian general paediatricians

OBJECTIVE: To identify which clinical situations are the most difficult to manage for general paediatricians in Victoria, Australia. METHODS: Self-administered questionnaires were sent to general paediatricians in Victoria. They were asked their opinions regarding what were the most difficult and the most dangerous clinical situations with which they deal. RESULTS: The response rate was 64% (63 out of 98 questionnaires sent). The general paediatricians surveyed believed that behavioural, developmental and psychosocial conditions were the most difficult to deal with; conduct disorder was the most nominated clinical category (26% of respondents). The 'dangerous' cases nominated were predominately traditional medical cases. The most commonly nominated category was sepsis and shock (21% of respondents). The most difficult and dangerous clinical situations overall for general paediatricians in Victoria appear to be in the areas of sepsis, child protection, paediatric and neonatal resuscitation, depression and suicide, raised intracranial pressure, intravenous fluid management, and communication with parents and adolescents. CONCLUSIONS: The present survey provides useful information to help with training-programme design and it gives trainee paediatricians an idea of what experienced paediatricians find difficult. Severe behavioural, family and social difficulties, as well as neonatal and childhood resuscitation, severe sepsis, raised intracranial pressure, and intravenous fluid management were the clinical situations most frequently described as difficult.     

Priorities and practice in tropical paediatrics

More than 14 million children under 5 years of age die annually in the Third World, mainly due to diarrhoea, pneumonia, malaria and immunizable diseases. The problems of poverty, malnutrition, poor sanitation, illiteracy and high fertility that traditionally are associated with underdevelopment are now being compounded by social disruption due to rapid changes in lifestyle, new diseases such as AIDS and Third World debt. A vital part of the solution is provision of basic medical and education services to all, with emphasis on female literacy and improving the status of women. Key elements in providing basic medical services are delegation and empowerment. Doctors must delegate the delivery of essential child health services to appropriately trained and adequately supported auxiliaries. Parents, especially mothers, need to be empowered with the knowledge and resources to recognize and manage, or assist in the management of, their children's health problems.     

Postgraduate training in paediatrics: Analysis of deficiencies as perceived by paediatricians

Abstract A listing of all general paediatricians in the country was obtained from the directory of members of the Australian College of Paediatrics. Each of the 287 paediatricians identified was sent a questionnaire requesting information about morbidity patterns of patients seen in their practices and their views regarding paediatric training. The response rate was 80.9%. Half the respondents had been in practice for 10 years or less, while two-thirds practised in a capital city. Respondents rated their training in each of 10 organic specialty areas, on average, as having been appropriate. However, when given a listing of nine areas related to child development and behaviour, chronic disease and counselling, 70% rated training in these areas as having been inadequate; this figure was even higher for recent graduates. Less than one-third had formal training in developmental, behavioural and community paediatrics; the remaining two-thirds of respondents acquired their knowledge by clinical experience, books or journals, professional contacts or meetings. This was despite the fact that almost 80% of respondents felt that practical experience was not an adequate substitute for formal training in developmental and behavioural paediatrics. There was an encouraging trend for paediatricians who had been in practice for 10 years or less to have had training in these areas, although the number was still less than half. Almost 90% of respondents felt that changes were needed in paediatric training to equip trainees for general paediatric practice, while 62% of respondents were of the opinion that the present FRACP training system mitigated against appropriate training for general paediatrics. Ninety-three per cent of respondents agreed that paediatricians had a major role to play in the management of children with problems of development and behaviour. Respondents made a large number of pertinent comments regarding perceived deficiencies in their training. These data are discussed in terms of the need to address imbalances in training. It is suggested that steps need to be taken to address the conflict between hospital service and training needs, that more trainees should be exposed to experiences in ambulatory and community settings, and that it is important to consider the introduction of appropriate curricula in developmental and behavioural paediatrics into Australian training programmes.     

Practical aspects of genetic testing in ambulatory paediatrics and child health care

BACKGROUND:

An overview of practical aspects of genetic testing in ambulatory practice in Canada.

OBJECTIVE:

To provide an overview and practical references for child health specialists and paediatricians on genetic services that can be provided to their patients.

METHODS/RESULTS:

A review and summary of areas of genetic testing options available across Canada.

CONCLUSIONS:

Modern Canadian paediatric practice requires office-based practitioners to fully understand and utilize genetics testing in their offices.     

Development and validation of a smoking media literacy scale for adolescents

OBJECTIVES: To develop a smoking media literacy (SML) scale by using empiric survey data from a large sample of high school students and to assess reliability and criterion validity of the scale. DESIGN: On the basis of an established theoretical framework, 120 potential items were generated, and items were eliminated or altered on the basis of input from experts and students. Cross-sectional responses to scale items, demographics, smoking-related variables, and multiple covariates were obtained to refine the scale and determine its reliability and validity. SETTING: One large Pittsburgh, Pa, high school. PARTICIPANTS: A total of 1211 high school students aged 14 to 18 years. MAIN OUTCOME MEASURES: Current smoking, susceptibility to smoking, attitudes toward smoking, and smoking norms. RESULTS: Factor analysis demonstrated a strong 1-factor scale with 18 items (alpha = 0.87). After controlling for all covariate data, SML had a statistically significant and independent association with current smoking (P = .01), susceptibility (P<.001), and attitudes (P<.001), but not norms (P = .42). Controlling for all covariates, an increase of 1 point on the 10-point SML scale was associated with a 22% decrease in the odds of being a smoker and a 31% decrease in the odds of being susceptible to smoking. CONCLUSIONS: Smoking media literacy can be measured with excellent reliability and concurrent criterion validity. Given the independent association between SML and smoking, media literacy may be a promising tool for future tobacco control interventions.     

Collaboration between child psychiatry and paediatrics: the state of the relationship in Norway

In Norway, the first paediatric department was founded in Oslo 100 years ago. The first child psychiatric department was opened in 1950. To assess qualitative and quantitative aspects of child psychiatric liaison work, questionnaires were sent to the heads of 25 paediatric departments and 53 child psychiatric units. Scarce child psychiatric resources were spent in paediatrics. The average score for satisfaction with collaboration was moderate (5.5 on a 10-cm visual analogue scale) and agreement between the parties was modest. Improvement will involve development of a common language and a shared model for understanding the psychosocial aspects of acute and chronic childhood illnesses. In-service training for paediatricians in child psychiatry and vice versa may help. Both parties indicated a need for more training in consultation/liaison and in multi-professional assessments and therapeutic interventions with children with physical illnesses.     

Residents as teachers in Canadian paediatric training programs: A survey of program director and resident perspectives

BACKGROUND:

The importance of the teaching role of residents in medical education is increasingly being recognized. There are little data about how this role is perceived within training programs or how residents develop their teaching skills. The aims of the present study were to explore the perspectives of Canadian paediatric program directors and residents on the teaching role of residents, to determine how teaching skills are developed within these programs, and to identify specific areas that could be targeted to improve resident teaching skills and satisfaction.

METHODS:

Program directors and residents in Canadian paediatric residency programs were surveyed about the scope of teaching performed by residents, resident teaching ability and resources available for skill development.

RESULTS:

Responses were received from 11 of 13 program directors contacted. Nine programs agreed to have their residents surveyed, and 41% of residents in these programs responded. Directors and residents agreed that residents taught the most on general paediatric wards, and that medical students and residents were the most frequent recipients of resident teaching. While 72% of directors reported that instruction in teaching was provided, only 35% of residents indicated that they had received such training. Directors believed that residents needed improvement in providing feedback, while residents wanted help with teaching at the bedside, during rounds and in small groups. Teaching performance was included in rotational evaluations in most programs, but residents were often uncertain of expectations and assessment methods.

CONCLUSION:

There is a general consensus that residents play an important teaching role, especially on the inpatient wards. Residents’ ability to fill this role could be enhanced by clearer communication of expectations, timely and constructive feedback, and targeted training activities with the opportunity to practice learned skills.     

Telling the truth to young children: Ethical reasons for information disclosure in paediatrics

When parents ask doctors not to disclose certain information to a child, doctors are challenged to articulate ethical reasons for giving information to children. This paper maps out the professional and legal landscape in which information‐giving to children is taking place and identifies the key ethical arguments that have been made for disclosure of information to the child patient. We focus on pre‐adolescent children, who have not reached a developmental stage that would see them regarded as ‘mature minors’. While doctors can be relatively certain that professional and legal requirements will endorse their disclosure of information to the ‘mature minor’, guidelines are not clear on information‐giving to pre‐adolescents (immature minors). We identify six ethical reasons for telling the truth to younger children. It is noteworthy that there are good reasons to tell the truth to children, which are independent of any question of the child's capacity to be involved in decision‐making.     

Diagnosis in developmental-behavioural paediatrics: the art of diagnostic formulation

This paper considers diagnostic frameworks in developmental-behavioural paediatrics. The purpose of a diagnostic assessment is reviewed, and the use of categorical diagnoses is explored. A multi-level process of diagnostic formulation is outlined, highlighting the importance of a comprehensive focus on presenting symptoms, neuropsychological constructs, biological factors and environmental influences. The axis of time, developmental benchmarks and the enhancement of resilience are discussed as part of the diagnostic formulation framework. Limitations imposed on diagnostic practice by systemic and personal factors are reviewed. Implications for training and practice are discussed.     

Volumetric bone mineral density — a potential role in paediatrics

The use of areal bone mineral density (aBMD) in paediatric populations has aroused some concern, as it fails to take the age-related increase in bone thickness into account. We have developed a measure of true bone density, volumetric bone mineral density (vBMD), which is independent of age and height. In order to examine the relationship between growth parameters, aBMD and vBMD, we studied patients with phenylketonuria (PKU, n = 40), chronic renal failure (CRF, n = 27) and chronic asthma (n = 19). aBMD of the femoral neck and the mid-femoral shaft was measured using dual energy X-ray absorptiometry (DXA), vBMD was calculated on the basis of values of bone mineral content and bone dimension provided by DXA, with the assumption that both sites are cylinders. aBMD and vBMD were then compared with the normal reference, expressed as a standard deviation score (SDS). aBMD and vBMD were normal in the femoral neck region of the PKU group, but aBMD, either standardized for age or for height, was low in the femoral shaft region ( p < 0.01). In the CRF group, profound growth retardation was seen (mean height SDS, −3.2) and aBMD and vBMD were both low in the femoral shaft region but not in the femoral neck. In the asthma group, aBMD for age was low at both sites, but vBMD did not differ from that seen in normal individuals. We conclude that the true vBMD provides a different interpretation of bone density compared with aBMD and requires further evaluation in paediatrics because of its age and height independence.     

Epidemiology of malpractice lawsuits in paediatrics

A systematic review of malpractice lawsuits involving children identified six articles and 227 cumulative paediatric published cases. The prevalence of medical lawsuits resulting in payment to plaintiff was found to be 50% less frequent than that in adults. The most frequent and severe errors were among infants, including diagnostic errors of meningitis, gastroenteritis and pneumonia. The most implied unit was emergency department (58%). The patients and/or families were compensated in 23- 68% of cases. CONCLUSION: These data can increase physicians' awareness of disorders and age groups at high risk of medical errors. This could lead to minimize the risk of medical malpractices and to improve patient safety.     

Do diagnosis related groups separate the case-mix of a specialist children's hospital and a paediatric unit in a general hospital?

The ability of diagnosis related groups (DRG) and refinement diagnosis related groups (RDRG) to measure differences in case-mix was investigated using discharge data for patients <18 years of age from three specialist children's hospitals and four district hospitals. While the three children's hospitals each had a greater percentage of RDRG for more complex patients, only one children's hospital had more complex patients based on DRG and RDRG cost weights and on the percentage of diagnoses per discharge. Cost weights based on USA practices may be inappropriate in Australia, and Australian weights will be necessary for firm conclusions. Refinement diagnosis related groups with appropriate cost weights may be acceptable measures of case-mix in specialist children's hospitals, but they have inherent limitations for paediatric patients in that many complex paediatric patients are ill very seriously with one disorder, whereas complex adult patients usually have secondary diagnoses and secondary procedures. Moreover, no DRG version developed in the US will be suitable for use in Australia unless it takes account of medical costs and transfer practice.     

Pride, prejudice, and paediatrics (women paediatricians in England before 1950)

Within the literature of the Enlightenment there are voices that called for the emancipation of women, and so began a--still unfinished--struggle for equality at home and in society. The campaign for women to enter the professions started in the 19th century. Women who wished to qualify and work as doctors faced what must have seemed to those of lesser courage and ability, to be insurmountable resistance. The early women doctors of the 19th century who were forced to obtain their training on the continent--in Zurich, Bern, and Paris--were part of a political movement and transatlantic network concerned with issues of women's rights, universal suffrage, women's health and public health measures. These women who "stormed the citadel" wanted to, and did, change society as well as medicine. Opposition to women's entry into medicine was led by doctors who defended the male monopoly against the threat to their prestige and purse. They argued that a woman's place was in the home as a wife and mother. Women's bodies, intellect, and temperament were not up to the demands of studying medicine, let alone practising as doctors. These arguments did not stop, but echoed down the 20th century long after women had gained the right to qualify in medicine.     

Development and validation of the ABC pain scale for healthy full-term babies

AIM: We developed and validated a pain scale (ABC scale) for term babies based on acoustic features of crying. METHODS: The scale consisted of three different cry parameters: (a) pitch of the first cry; (b) rhythmicity of the crying bout; (c) constancy of crying intensity. These parameters were previously found to distinguish between medium and high levels of pain measured by spectral analysis of crying. We validated the scale using healthy term babies undergoing routine heel prick. Concurrent validity was assessed comparing pain values obtained with our scale with those obtained with another pain scale; this relationship was also used to assess the sensitivity of the scale. To assess specificity we compared the ABC scores during a painful event (heel prick) with two non-painful events (preliminary phase of prick in the same group of babies, and heel prick with analgesia in another group). RESULTS: Specificity: (a) analgesic/non-analgesic comparison, p < 0.0001; (b) pain/sham comparison, p < 0.0001). Sensitivity: a high correlation between scores of the ABC scale and the Douleur Aigue du Nouveau-Né scale indicates good sensitivity. Concurrent validity: Spearman rho = 0.91. Internal consistency: Cronbach's alpha = 0.76. Inter-rater reliability: Cohen's kappa for multiple raters = 0.83. Intra-rater reliability: Cohen's kappa = 0.85. Practicality: All nurses who used it scored the scale as "good". CONCLUSION: The ABC scale proved to be simple and reliable for assessing pain in healthy, non-intubated term newborns.     

Annotation Medical student education in paediatrics and child health: Where are we going?

In most undergraduate medical curricula, learning is becoming less content based and the emphasis is changing to problem based learning, continuing self directed learning, and the use of a wide range of learning resources. Particular needs in paediatrics and child health are an increasing emphasis on learning in ambulatory care and community based health facilities, and on assessment processes which are formative and reflect the learning objectives appropriately. A wide range of resources is needed for learning at a time when teaching hospital and health system facilities face significant financial restraints.