Determining the benefits and objectives of a child health residency program for Canadian rural family physicians: An international qualitative research study

OBJECTIVES:

To clarify the need for an advanced child health training program for Canadian rural family physicians, and to determine the key learning objectives to enable graduates to become community leaders in child and youth health care.

DESIGN:

Qualitative educational research study.

Setting:

Canada and Australia.

METHODS:

To gather data, the authors carried out semistructured interviews and focus groups with child care consultants, Canadian rural family physicians, child patients and parents, family medicine residents and Australian rural family physicians. Standards of qualitative methodology were applied to identify themes and subthemes.

RESULTS:

It was determined that a family medicine child health program would provide the following benefits: enhanced care by family physicians, improved access to child care, increased attractiveness of family medicine as a career and reduced ‘specialty burden’.Five key learning objectives for graduates were identified: the ability to provide child-centred care, to care for acutely or critically ill children, to care for children with complex needs, to recognize and act on ‘red flags’, and to provide behavioural and mental health care.The Australian general practitioners confirmed that their training provided most of these benefits, and enabled them to achieve the objectives identified.

CONCLUSION:

The present study showed that multiple stakeholders believed that advanced training in child health for rural family physicians would provide better care for children. The study also identified key learning objectives for the program. The present research led to the establishment of a Family Medicine Child Health Residency Program (www.familymedicineuwo.ca/PostGrad/PGY3/ChildHealth.aspx) at The University of Western Ontario (London, Ontario).     

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.     

Interdisciplinary child protection team work in a hospital setting

Introduction A retrospective study consisting of a data analysis of the Salzburg Child Protection Team (CPT) documentation and medical documentation was carried out. The objective was to investigate the frequency and distribution of maltreatment diagnoses and the spectrum of clinical symptoms of children reported to the interdisciplinary Salzburg CPT between 1996 and 2001.Results and discussion The documentation covered a total of 286 children and adolescents (117 boys, 169 girls; mean age: 6.9±4.9 years) that the CPT suspected of being maltreated. The annual mean frequency of children reported to the CPT was 0.72% of all inpatients, with maltreatment being confirmed in 0.44% of the cases (61.2% of the children reported). The maltreatment could be classified into physical (26.9%), sexual (14.0%), neglect (17.5%) and Munchhausen’s syndrome by proxy (2.4%). In 17.5% of the suspected cases the suspicion of maltreatment was subsequently judged to be incorrect, while in 21.7% of the cases, doubt remained. In 43% of all cases the suspected perpetrators were one or both parents, and in 8.3% the perpetrator was a person from outside the family. The police were informed in 20.3% of the cases, and the Youth Welfare Department was informed in 62.6% of the cases. In conclusion, the frequency of maltreatment diagnoses is lower than expected.Conclusion Although the work of CPT can be considered to be effective and useful, better diagnostic selectivity and specificity and a long-term follow-up are required.This study was funded by a grant awarded to KNIFFF (Institute for Education and Research in Child and Adolescent Neuropsychiatry) by the Creditanstalt Bankverein, Salzburg and “Licht ins Dunkel”, Vienna, Austria.     

Primary caregivers’ experience with the informed consent process in the paediatric emergency department: An interview-based qualitative study

ObjectiveThis study aims to understand primary caregivers’ (PCG) experience with the informed consent (IC) process.MethodsWe conducted in-depth interviews with PCGs of paediatric patients who underwent a procedure requiring IC in the paediatric emergency department (PED) of a tertiary care paediatric centre in the USA, between January and March 2013 and between September 2013 and January 2014. We triangulated the qualitative findings from the PCG interviews with Likert-scale responses from the PCGs and with results from surveyed physicians.ResultsWe included 14 PCG–physician dyads. Our results show that PCGs understand the importance of the IC process. They appreciated the calm demeanor of providers, and the clarity of their wording. PCGs felt that IC can add to the stress, and that it could be made simpler and timelier. PCGs also had varying extents of retention of the information provided.ConclusionThis exploratory study suggests an overall positive IC experience of the PCGs while highlighting areas for improvement including a more thorough discussion of alternatives, a better assessment of knowledge transmission and retention by the PCG, and recognition of the PCG’s discomfort during decision making in a stressful environment.     

Acute rib fracture diagnosis in an infant by US: a matter of child protection

Rib fractures in infants and children are highly specific for inflicted injury in the absence of a major accidental injury or underlying bone disorder. We present a 9-week-old infant diagnosed with an acute rib fracture by US at the site where physicians palpated chest wall crepitus when no rib fractures had been visualized on the skeletal survey, including oblique views of the ribs. Based on the US diagnosis of the acute rib fracture the infant was taken into protective custody. Follow-up skeletal survey 2 weeks later revealed healing fractures of the left 6th and 7th posterolateral ribs and right 7th, 8th and 9th anterolateral ribs. We were unable to locate previous reports describing the diagnosis of rib fractures in infants by US.     

Physiological referrals for paediatric musculoskeletal complaints: A costly problem that needs to be addressed

BACKGROUND/OBJECTIVE:

Referrals to paediatric orthopedists for physiologically normal conditions consume limited resources and delay care for patients. The goal of the present study was to formally define such referrals and determine their prevalence.

METHODS:

A retrospective review evaluated consecutive referrals to a single tertiary paediatric orthopedic centre over two eight-month periods. Referrals from family physicians and paediatricians were retained for analysis. Physiological referrals were defined as a final orthopedic diagnosis of ‘within physiological norms’; and no scheduled follow up.

RESULTS:

Physiological conditions represented 22.5% of referrals. The type of referring physician did not determine referral quality. Flat foot, intoeing and genu varum/valgum exhibited physiological referral rates that exceeded 40%.

CONCLUSION:

Physiological referrals constitute a large portion of the outpatient paediatric orthopedic practice and represent a substantial unnecessary cost to the Canadian medical system. Future strategies to improve referral quality should target undergraduate and postgraduate musculoskeletal education.     

Severe child abuse: a study of cases reported to the police

AIM: To investigate the characteristics of severe abuse of children and possible differences in comparison with less severe abuse. METHOD: Cases of abuse reported to the police within a single police district (n=142) in Sweden were studied. The severe cases were compared to all the remaining cases. RESULTS: Severe abuse constituted 14% of the total cases and was reported by agencies to a greater degree than minor cases. The suspected perpetrators were socially disadvantaged people in both groups. Half of the most serious cases led to conviction in the courts, compared to 8% in the reference group. The children who had been subjected to abuse were often already known to social services and reports of child abuse had frequently been made. CONCLUSION: In comparison between cases of severe and minor child abuse reported to the police, the results did not show any crucial differences except the pattern of reporting and a higher occurrence of prosecution/conviction in the severe cases. This finding places a responsibility on agencies outside of the justice system to consider all cases of reported abuse as serious warning signals and to make independent evaluations to identify risks and the possible need for child protection.     

Ethics application protocols for multicentre clinical studies in Canada: A paediatric rheumatology experience

INTRODUCTION:

Individual institutions govern research ethics applications and each must administer and regulate their own protocols. Variations in ethics review procedures and expectations among centres impose impediments to efficiently conducting multicentre studies.

METHODS:

Observations relating to preparing multisite ethics documents for a study conducted by Canadian paediatric rheumatology investigators are described. Research ethics applications from the 12 participating centres were compared.

RESULTS:

Although the applications were similar in their content, they differed in their formatting. All applications shared a commitment to ensuring that the study conformed to exemplary ethical standards.

CONCLUSIONS:

There is wide variation in the multicentre clinical study ethics application process at the institutional level. Considering the common fundamental elements required by all ethics review boards, the present study conceptualized introducing a discipline-specific uniform ethics application process acceptable to all Canadian research ethics boards. This may be a more efficient strategy that could help lessen the burden of collaborative research.     

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.     

Patterns of reporting by health care and nonhealth care professionals to child protection services in Canada

BACKGROUND:

All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. The present study examined the types of maltreatment, level of harm and child functioning issues (controlling for family socioeconomic status, age and sex of the child) reported by health care and nonhealth care professionals.

METHODS:

χ² analyses and logistic regression were conducted on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003), and the differences in professional reporting were compared with its previous cycle (CIS-1998) using Bonferroni-corrected CIs.

RESULTS:

Analysis of the CIS-2003 data revealed that the majority of substantiated child maltreatment was reported to service agencies by nonhealth care professionals (57%), followed by other informants (33%) and health care professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while nonprofessional reports increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (P<0.001). Compared with nonhealth care professionals, health care professionals more often reported younger children, children who experienced neglect and emotional maltreatment, and those assessed as suffering harm and child functioning issues, but less often reported exposure to domestic violence.

CONCLUSION:

The results indicate that health care professionals play an important role in identifying children in need of protection, considering harm and other child functioning issues. The authors discuss the reasons why under-reporting is likely to remain an issue.     

Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.     

The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective

Bruises commonly occur in children and are most often the result of a minor accidental injury. However, bruises can also signal an underlying medical illness or an inflicted injury (maltreatment). Although bruising is the most common manifestation of child physical maltreatment, knowing when to be concerned about maltreatment and how to assess bruises in this context can be challenging for clinicians. Based on current literature and published recommendations, this practice point will help clinicians to distinguish between accidental and inflicted bruises, to evaluate and manage bruising in the context of suspected child maltreatment, and to evaluate for an underlying medical predisposition to bruising.     

Intracranial bleeding from child abuse: The value of skull radiographs

Two infants with intracranial bleeding are described. Each had extensive evaluations aimed at uncovering vascular anomalies or bleeding diatheses. Plain skull radiographs that demonstrated fractures led to the correct diagnosis of child abuse. This report serves to emphasize the value of the plain skull radiograph in the evaluation of infants with intracranial bleeding.     

The impact of humanoid robot presence in the paediatric emergency department waiting room: A prospective cohort study

BackgroundThe waiting room represents families’ first point of contact with the emergency department (ED). We wished to study if a humanoid robot technology presence in the waiting room would improve satisfaction and decrease anxiety for caregivers in the paediatric ED. MethodsThis observational cohort study was conducted from September to December 2018 at a Canadian paediatric ED. All caregivers and children >11 years in the ED waiting room were eligible. We compared a robotic intervention (RI) to standard of care (SOC) education in the waiting room. The RI was a 5-minute psychoeducational program describing the ED process and flow. Specific days were designated for RI or SOC. An anonymous survey was administered twice, at the same times, on both SOC and RI days. The primary outcomes were (a) caregiver satisfaction with waiting room experience using a 5-point Likert scale; and (b) caregiver-reported anxiety in the waiting room, as measured by the State Trait Anxiety Inventory – State Scale. ResultsSix hundred and thirty-three caregivers participated, with a median age of 37 years (IQR 32 to 42); 80 children participated, with a median age of 15 years (IQR 13 to 16). Caregivers reported greater overall satisfaction in the RI cohort (174/200, 87.0%) compared to the SOC cohort (144/229, 62.9%; P<0.0001). Caregivers also reported lower anxiety in the RI cohort (39.38±11.38) compared to the SOC cohort (42.04±11.99; P=0.009).ConclusionsA humanoid robot-based psycho educational intervention in the paediatric ED waiting room has a positive impact on caregiver satisfaction and anxiety.