Incorporating CanMEDS and subspecialty training into paediatric residency programs: Why are we still deficient?

BACKGROUND:

The Royal College of Physician and Surgeons of Canada mandates that paediatric training programs in Canada incorporate subspecialty training and the teaching and evaluation of the seven CanMEDS roles into their curriculum. The literature suggests that newly practicing paediatricians feel inadequately prepared in many subspecialties and CanMEDS roles.

HYPOTHESIS:

That either current training programs underestimate the importance of these areas for future practice, or that residents themselves feel that these areas are less important.

METHOD:

An online survey of Canadian paediatric residents and paediatric residency program directors was conducted to determine their views on various subspecialty areas and CanMEDS roles.

RESULTS:

Fourteen of 16 Canadian paediatric programs participated, and 127 of 486 (26%) paediatric residents completed the survey. Overall, trainees were satisfied with their current training (86%), and 90% believed they would be adequately prepared for independent practice. Forty-six residents (40%) believed training programs place less importance on 10 of the subspecialties that newly practicing paediatricians felt less comfortable with (from a previous study conducted in 2006). However, at least 25% of residents themselves placed less importance on nine of these 10 areas. Residents also place less importance on two CanMEDS competencies which practicing paediatricians felt less comfortable with, including the medical aspects of palliative care (medical expert) and managing an efficient office practice (manager).

CONCLUSIONS:

Residents and programs place less importance on specific areas of paediatric training, thus creating potential deficiencies in graduating paediatricians. Promotion of these topics during training may better prepare residents for future practice.     

Paediatrician office follow-up of common minor fractures

BACKGROUND:

Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs).

OBJECTIVES:

To determine PCP opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office.

METHODS:

An online survey was sent between June and September 2013 to all paediatricians who subscribed to the American Academy of Pediatrics PROS-Net Listerv and to those who were registered with the Scott’s Canadian Medical Directory as paediatricians who treated children in a primary care capacity. The primary outcome was the proportion of PCPs who agreed with PCP follow-up of minor paediatric fractures. Secondary outcomes included PCP’s perceived barriers to office follow-up.

RESULTS:

A total of 1752 surveys were sent; 1235 were eligible and 459 (37.2%) responded to the survey. Overall, 296 (69.5% [95% CI 65.2% to 74.0%]) PCPs agreed that minor paediatric fractures could be followed in a PCP office. The most frequently reported barriers were lack of materials to replace immobilization (58.1%), PCP knowledge deficits (44.8%) and a perceived parental preference for an orthopedic surgeon (38.6%). Finally, 58.8% of respondents believed that further education was necessary if PCPs assumed responsibility for follow-up of midshaft clavicle fractures, while 66.5% and 77.1% (P<0.0001) believed this was necessary for distal radius buckle and fibular fractures, respectively.

CONCLUSIONS:

More than two-thirds of responding PCPs in Canada and the United States agreed that minor common paediatric fractures can be followed-up by paediatricians. However, PCPs reported some barriers to this management strategy, including a desire for more education on this topic.     

Demographic characteristics and needs of families at an urban,low-income,multicultural paediatric clinic

OBJECTIVES:

To describe the demographic characteristics and identify the needs of a population attending an urban, low-income area, multicultural paediatric clinic.

METHODS:

Surveys were distributed to caregivers of children zero to 16 years of age (n=299).

RESULTS:

Of the children attending appointments, 55% were female and 51% were five years of age or younger. Of the caregivers, 29.5% were born outside of Canada and 25% reported that their primary spoken language was not English. Sixty-six per cent of families had been living in Edmonton for more than three years, with two-thirds of respondents living in Edmonton’s second-lowest average household income region. Seventy-six per cent of respondents lived in households with four or more persons.

CONCLUSIONS:

Challenges facing individuals attending an urban, low-income area, paediatric clinic include language barriers, lower household income and larger family size. Immigrants living outside of major Canadian cities are under-represented and may have different needs compared with their counterparts in ‘gateway’ cities. More studies are needed to determine their needs, and will ultimately lead to the provision of culturally competent care.     

Capacity building for child health: Canadian paediatricians in Uganda

BACKGROUND

For six years, Canadian paediatricians have worked in partnership with their Ugandan colleagues to promote improved child health in southwestern Uganda.

OBJECTIVES

To describe a collaboration between the Mbarara University of Science and Technology and Canadian partners that aims to build local capacity in child health through support of training at university, community and health centre levels.

METHODS

Three low-cost initiatives are now implemented. At the university level, volunteer Canadian paediatricians support Ugandan faculty colleagues through teaching health care trainees at a busy tertiary referral and teaching hospital. In the community, the Healthy Child Project helps Ugandans train local health volunteers who educate mothers and caregivers about child health. At health centres in the Mbarara and Bushenyi Districts, Canadians support a locally initiated outreach program that provides paediatric consultation and continuing medical education for staff at rural health posts.

RESULTS

Ugandans and Canadians have benefited from this collaboration. Hundreds of Ugandan undergraduate and graduate health care trainees, more than 100 community volunteers and numerous local health practitioners have received child health training through one of these three Canadian-supported paediatric initiatives. More than 25 Canadian paediatricians have benefited greatly from their overseas teaching and clinical experience.

CONCLUSIONS

The strength of this collaboration is a shared interest in improving child health in southwestern Uganda. A strong Ugandan-Canadian partnership has built significant child health capacity with great benefit to both partners. These initiatives may serve as a model for other child health providers wishing to support capacity-building initiatives in less developed countries to improve global health.     

Paediatricians’ awareness of children’s oral health: Knowledge,training, attitudes and practices among Turkish paediatricians

BACKGROUND:

In Turkey, 74.1% of children between three and six years of age develop dental caries.

OBJECTIVE:

To assess the depth of oral health and dental knowledge among paediatricians in Turkey, to determine their level of oral health education and to determine factors that were associated with higher knowledge scores.

METHODS:

A cross-sectional survey of demographics that assessed the participants’ knowledge of oral and dental health, attitudes regarding oral health during well-child visits and opinions regarding infant oral health care visits was conducted. The outcome variables were the proportions of paediatricians who adhered to good clinical practice guidelines, recommended dental visits for children younger than one year of age, and having a knowledge score >50%.

RESULTS:

The participant characteristics that were significantly associated with a greater mean number of correct answers were female sex, good clinical practice, confidence in detecting dental caries and the presence of a dentistry department in their hospital (P=0.001, P<0.001, P<0.001 and P=0.02, respectively). Only 13.9% of paediatricians referred children younger than one year of age to a dentist. After adjusting for the level of oral health education received during residency training, sex and having children, only the knowledge score was significantly associated with referring patients younger than one year of age to a dentist (P=0.01).

CONCLUSIONS:

Some paediatricians’ knowledge was found to be associated with practices that were in accordance with professional society recommendations. The lack of dental knowledge and training in residency limits the paediatricians’ role in promoting children’s oral health in daily practice.     

Implementation and evaluation of a simulation curriculum for paediatric residency programs including just-in-time in situ mock codes

OBJECTIVE:

To develop, implement and evaluate a simulation-based acute care curriculum in a paediatric residency program using an integrated and longitudinal approach.

DESIGN:

Curriculum framework consisting of three modular, year-specific courses and longitudinal just-in-time, in situ mock codes.

SETTING:

Paediatric residency program at BC Children’s Hospital, Vancouver, British Columbia.

INTERVENTIONS:

The three year-specific courses focused on the critical first 5 min, complex medical management and crisis resource management, respectively. The just-in-time in situ mock codes simulated the acute deterioration of an existing ward patient, prepared the actual multidisciplinary code team, and primed the surrounding crisis support systems. Each curriculum component was evaluated with surveys using a five-point Likert scale.

RESULTS:

A total of 40 resident surveys were completed after each of the modular courses, and an additional 28 surveys were completed for the overall simulation curriculum. The highest Likert scores were for hands-on skill stations, immersive simulation environment and crisis resource management teaching. Survey results also suggested that just-in-time mock codes were realistic, reinforced learning, and prepared ward teams for patient deterioration.

CONCLUSIONS:

A simulation-based acute care curriculum was successfully integrated into a paediatric residency program. It provides a model for integrating simulation-based learning into other training programs, as well as a model for any hospital that wishes to improve paediatric resuscitation outcomes using just-in-time in situ mock codes.     

Adverse events associated with paediatric use of complementary and alternative medicine: Results of a Canadian Paediatric Surveillance Program survey

BACKGROUND

Despite many studies confirming that the use of complementary and alternative medicine (CAM) by children is common, few have assessed related adverse events.

OBJECTIVE

To conduct a national survey to identify the frequency and severity of adverse events associated with paediatric CAM use.

METHODS

Survey questions were developed based on a review of relevant literature and consultation with content experts. In January 2006, the Canadian Paediatric Surveillance Program distributed the survey to all paediatricians and paediatric subspecialists in active practice in Canada.

RESULTS

Of the 2489 paediatricians who received the survey, 583 (23%) responded. Respondents reported that they asked patients about CAM use 38% of the time and that patients disclosed this information before being questioned only 22% of the time. Forty-two paediatricians (7%) reported seeing adverse events, most commonly involving natural health products, in the previous year. One hundred five paediatricians (18%) reported witnessing cases of delayed diagnosis or treatment (n=488) that they attributed to the use of CAM.

CONCLUSION

While serious adverse events associated with paediatric CAM appear to be rare, delays in diagnosis or treatment seem more common. Given the lack of paediatrician-patient discussion regarding CAM use, our findings may under-represent adverse events. A lack of reported adverse events should not be interpreted as a confirmation of safety. Active surveillance is required to accurately assess the incidence, nature and severity of paediatric CAM-related adverse events. Patient safety demands that paediatricians routinely inquire about the use of CAM.     

Paediatricians�� validation of learning objectives in paediatric cardiology

BACKGROUND

The current objectives for teaching paediatric cardiology to paediatric residents have not been validated and may not be relevant to current paediatric practice.

OBJECTIVES

To validate the cardiology component of the Royal College of Physician and Surgeons of Canada’s objectives for training paediatricians.

METHODS

A questionnaire was sent to practising paediatricians in Atlantic Canada. The questions were based on the Royal College of Physician and Surgeons of Canada’s training objectives. The frequency of problems seen, confidence in assessment and management of problems, and reasons for referral were identified. Clinical vignettes were followed by short questions. The outpatient referrals were reviewed to validate the questionnaire responses.

RESULTS

One hundred fifty-one questionnaires were mailed and the response rate was 60%. Murmurs were the most common problem encountered (92%). Syncope (9%), Kawasaki disease (8%) and chest pain (6%) were less frequently encountered. Paediatricians were confident in assessing and managing problems despite the low frequency of encounters. Less confidence was expressed regarding physical examination skills and interpretation of electrocardiograms. Uncertainty of the diagnosis was the most common reason for patient referral, with parental anxiety and medicolegal concerns accounting for 24% and 7% of referrals, respectively. Syncope with exercise was relatively poorly recognized as a worrisome symptom.

CONCLUSIONS

Most cardiology objectives for general paediatric training remain relevant and appropriate to clinical practice. Physical examination skills, electrocardiogram interpretation and the assessment of syncope need to be emphasized.     

The CanMEDS role of Collaborator: How is it taught and assessed according to faculty and residents?

OBJECTIVE:

To explore the perspectives of paediatric residents and faculty regarding how the Collaborator role is taught and assessed.

METHODS:

Using a constructivist grounded theory approach, focus groups at four Canadian universities were conducted. Data were analyzed iteratively for emergent themes.

RESULTS:

Residents reported learning about collaboration through faculty role modelling but did not perceive that it was part of the formal curriculum. Faculty reported that they were not trained in how to effectively model this role. Both groups reported a need for training in conflict management, particularly as it applies to intraprofessional (physician-to-physician) relationships. Finally, the participants asserted that current methods to assess residents on their performance as collaborators are suboptimal.

CONCLUSIONS:

The Collaborator role should be a formal part of the residency curriculum. Residents need to be better educated with regard to managing conflict and handling intraprofessional relationships. Finally, innovative methods of assessing residents on this non-medical expert role need to be created.     

Residents as health advocates: The development, implementation and evaluation of a child advocacy initiative at the University of Toronto (Toronto, Ontario)

BACKGROUND AND OBJECTIVE:

Advocacy is an integral part of a paediatrician’s role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario).

METHODOLOGY:

Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents.

RESULTS:

Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback.

CONCLUSIONS:

Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.     

Paediatric primary care quality and accessibility: Parents�� perspective

OBJECTIVE

To measure parents’ satisfaction with paediatric primary care quality and accessibility.

BACKGROUND

High-quality paediatric primary care is a cornerstone of efforts to improve health outcomes and access to care, as well as to control health care spending. A strong primary care infrastructure is related to improved health outcomes, including an improved mortality rate.

METHODS

A cross-sectional survey using the Parents’ Perception of Primary Care questionnaire and evidence-based items from the Rourke Baby Record were used to measure parents’ satisfaction.

RESULTS

Of 200 questionnaires sent, 130 were returned. The mean number of children per family was 1.7±0.8 (mean ± SD). Sixty-six per cent of children received their primary care from general practitioners, 19% received their primary care from paediatricians, and 15% had no regular physician and identified other professionals (community nurses, midwives or chiropractors) as their primary care providers. Parents were questioned about their child’s hearing in 66% of cases. Only 41% of parents received guidance about breastfeeding, 37% about adequate sleeping position, 17% about the dangers of second-hand smoke and 16% about car safety seats. The level of satisfaction with communication, contextual knowledge and coordination of care was higher for families followed by general practitioners and paediatricians than for families followed by nonphysicians. According to the Parents’ Perception of Primary Care scores, the overall satisfaction with primary care was higher for care given by general practitioners and paediatricians than for care given by midwives or chiropractors, and intermediate when given by nurses.

CONCLUSION

In this survey, the majority of children received their primary care from physicians, most commonly general practitioners. Parents’ overall satisfaction regarding their infant’s primary health care was higher when it was delivered by physicians than by alternative health care providers. Evidence-based guidance recommendations were rarely followed.     

Childhood overweight and obesity management: A national perspective of primary health care providers' views, practices, perceived barriers and needs

BACKGROUND:

Obesity and overweight in children are an escalating problem in Canada and worldwide. Currently, little is known about the manner in which primary health care providers are responding to Canada’s obesity epidemic.

OBJECTIVE:

To determine the views, practices, challenges/barriers, and needs of a national sample of family physicians (FPs) and community paediatricians (CPs) with respect to paediatric obesity identification and management.

METHODS:

A self-administered questionnaire was mailed to a random sample of 1200 FPs and 1200 CPs across Canada between 2005 and 2006.

RESULTS:

A total of 464 FPs and 396 CPs participated. The majority of practitioners viewed paediatric obesity as an ‘important’/‘very important’ issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice to their overweight/obese patients, practitioners’ perceived success rate in treating paediatric obesity was limited (less than 22%). Approximately 30% of FPs and 60% of CPs (P<0.05) used the recommended method to identify paediatric obesity. At least 50% of practitioners indicated that too few government-funded dietitians, a lack of success in controlling paediatric patients’ weight, time constraints and limited training were key barriers to their success. To support efforts to identify or manage paediatric obesity, practitioners identified the need for office tools, patient educational materials and system-level changes.

DISCUSSION:

Canadian primary health care providers are not adequately equipped to deal with the paediatric obesity epidemic. Effective assessment tools and treatment resources, dissemination of clinical practice guidelines, enhanced undergraduate medical education and postgraduate continuing medical education, and system-level changes are urgently needed to address this health problem.     

Early childhood caries and infant oral health: Paediatricians�� and family physicians�� knowledge, practices and training

OBJECTIVES

To assess the knowledge of early childhood caries and to examine the current preventive oral health-related practices and training among Canadian paediatricians and family physicians who provide primary care to children younger than three years.

METHODS

A cross-sectional, self-administered survey was mailed to a random sample of 1928 paediatricians and family physicians.

RESULTS

A total of 1044 physicians met the study eligibility criteria, and of those, 537 returned completed surveys, resulting in an overall response rate of 51.4% (237 paediatricians and 300 family physicians). Six questions assessed knowledge of early childhood caries; only 1.8% of paediatricians and 0.7% of family physicians answered all of these questions correctly. In total, 73.9% of paediatricians and 52.4% of family physicians reported visually inspecting children’s teeth; 60.4% and 44.6%, respectively, reported counselling parents or caregivers regarding teething and dental care; 53.2% and 25.6%, respectively, reported assessing children’s risk of developing tooth decay; and 17.9% and 22.3%, respectively, reported receiving no oral health training in medical school or residency. Respondents who felt confident and knowledgeable and who considered their role in promoting oral health as “very important” were significantly more likely to carry out oral health-related practices.

CONCLUSION

Although the majority of paediatricians and family physicians reported including aspects of oral health in children’s well visits, a reported lack of dental knowledge and training appeared to pose barriers, limiting these physicians from playing a more active role in promoting the oral health of children in their practices.     

Early neonatal discharge guidelines: Have we dropped the ball?

OBJECTIVES:

To determine patterns of follow-up and prenatal education by family physicians and to assess whether practice patterns comply with the 1996 Canadian Paediatric Society/Society of Obstetricians and Gynecologists of Canada (CPS/SOGC) guidelines for early neonatal discharge.

DESIGN:

Mail survey.

SETTING:

A community of 300,000 people who were served exclusively for obstetrical care by a tertiary care hospital that performs 5000 deliveries per year and provides an early discharge program (EDP).

PARTICIPANTS:

Family physicians who provide prenatal and/or newborn care.

MAIN OUTCOME MEASURES:

The timing of neonatal follow-up and parental teaching by family physicians.

RESULTS:

Thirty-two per cent of the respondents scheduled their first postnatal visits two or more weeks after early discharge. There was no significant difference (P=0.7) in scheduling of follow-up for babies who were part of an EDP compared with those who were not. Fewer than 20% of physician respondents provided antenatal education in preparation for early discharge.

CONCLUSIONS:

The 1996 CPS/SOGC guidelines for physician follow-up after early neonatal discharge and for anticipatory parental education are not being followed consistently; however, these guidelines were disseminated without reinforcement. Until further study supports a change in practice guidelines, appropriate implementation strategies must be employed to ensure compliance.     

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.     

Paediatrician human resource planning in Canada: A 10-year follow-up

BACKGROUND

Paediatrician human resource planning in Canada is currently a major concern. The optimal mix of physicians by type of practice and geographical distribution also remains controversial for many groups of physicians.

OBJECTIVE

To compare 10-year trends (1987 to 1997) in paediatric practice with respect to age, sex and percentage of paediatricians practicing tertiary care.

METHODS

Information on the demographics and practice patterns of Canadian paediatricians obtained from national surveys conducted in 1987 and 1997 was examined.

RESULTS

In the 1987 survey, 1960 paediatricians were mailed a questionnaire, and 1352 questionnaires were returned (response rate of 69%). In the 1997 survey, 1706 of 2337 paediatricians returned the completed questionnaire (response rate of 73%). In 1987, 26.2% of paediatricians were women compared with 38.5% in 1997 (P<0.0001). When men and women were combined, 14.5% of paediatricians were in the 25- to 34-year age bracket in 1987, compared with only 9.7% in 1997 (P=0.0002). In 1987, 37.7% of paediatricians reported practicing tertiary care versus 38.7% in 1997 (P=0.61). In addition, tertiary care paediatricians have become more centralized in communities with more than 100,000 people.

CONCLUSIONS

The results confirm that the paediatric workforce is aging, located primarily in large urban areas and shifting toward more women. Shortages of paediatricians, especially in remote and rural areas, continue to be a major concern and show no signs of improvement. The potential impact of these changes on delivery and quality of child-care services in the future needs to be assessed.     

e-Health? Clinical information network interest and impediments in a community paediatric setting

BACKGROUND:

Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities.

OBJECTIVE:

To examine Ontario’s community care paediatricians’ electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN).

DESIGN:

Cross-sectional, interviewer-facilitated, structured survey.

POPULATION STUDIED:

Paediatricians providing community care in the Central West Ontario Health Region.

MAIN RESULTS:

Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners.

CONCLUSIONS:

Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.     

A needs assessment for obesity-related anticipatory guidance in the paediatric emergency department

BACKGROUND:

The prevalence of Canadian childhood obesity has been increasing, resulting in a call for improved prevention efforts and anticipatory guidance.

OBJECTIVE:

To evaluate interest in obesity-related anticipatory guidance in a paediatric emergency department.

METHODS:

Between September 2005 and September 2006, parents or patients older than 14 years of age were approached at the emergency department of the Children’s Hospital (London, Ontario) to complete a survey. The survey compiled demographic data and asked questions regarding self-perceived weight status, use of dieting and/or exercise for weight loss, desire for nutrition and/or exercise information, and interest in receiving anticipatory guidance related to obesity.

RESULTS:

Two hundred people completed the survey; the vast majority (92%) of respondents were parents. The mean (± SD) age of the children was 12.6±3.9 years. Forty-one per cent of the respondents indicated an interest in further information on obesity (95% CI 34% to 48%). Fifty-two per cent of respondents considered themselves overweight or obese (95% CI 45% to 59%), and 52% reported someone in their family who was dieting, exercising or both to lose weight. Parents who stated that their children considered themselves to be overweight or obese were significantly less interested in anticipatory guidance than parents who did not believe that their children considered themselves to be overweight or obese (67% versus 90%, respectively; P=0.009).

DISCUSSION:

Many patients in the paediatric emergency department desire information on nutrition and exercise. Further research into risk-stratified targeting of patients and parents are needed to help identify good candidates for anticipatory guidance.