Canadian Paediatric Residency Research Articles

Lost in translation: a national cross-sectional study on medical interpreter use by pediatric residents.

Lack of communication in a family's preferred language is inequitable and results in inferior care. Pediatric residents provide care to many families with non-English or French language preferences (NEFLP). There is no data available about how Canadian pediatric residents use interpreters, making it difficult to develop targeted interventions to improve patient experience. Our purpose was to assess translation services in pediatric training centers and evaluate resident perception of their clinical skills when working with NEFLP patients and families. This survey represents the first collection of data from Canadian pediatric residents about interpreter services. Eligible participants included all pediatric residents enrolled in an accredited Canadian pediatric training program. An anonymous survey was developed in REDCap© and distributed via email to all pediatric residents across Canada. Descriptive statistics were performed in STATA v15.1. 122 residents responded. Interpreter services were widely available but underused in a variety of clinical situations. Most (85%) residents felt they provided better care to patients who shared their primary language (English or French), compared with families who preferred other languages-even when an interpreter was present. This finding was consistent across four self-assessed clinical skills. Residents are more confident in their clinical and communication skills when working with families who share their primary language. Our findings suggest that residents lack the training and confidence to provide equal care to families with varying language preferences. Pediatric training programs should develop curriculum content that targets safe and effective interpreter use while reviewing non-spoken aspects of cultural awareness and safety.

28 Lost in Translation: Canadian Paediatric Resident Education and Practice of Clinical Translation Services

Abstract Background Canadian paediatric residents provide care to many families with non-English or French language preferences (NEFLP). Lack of communication in a family’s preferred language is inequitable and results in inferior care. Professional medical interpreters offer a route to enhanced understanding and safety. There is no data available about Canadian paediatric residents’ use of interpreters, making it difficult to identify gaps in practice or develop targeted interventions to improve patient experience. Objectives An anonymous, 19-item survey (REDCap) was designed to evaluate: (1) interpreter services available in paediatric training centers; (2) resident perception of their ease of access, utility, and value; and (3) barriers and drivers to interpreter use. This survey represents the first collection of data from Canadian paediatric residents about translator services. Design/Methods Eligible participants included all paediatric residents enrolled in an accredited Canadian paediatric training program. The survey was distributed by email and available for a three-month period. This project was reviewed and considered within the category of quality improvement and thus exempt from formal review by the hospital ethics committee. Descriptive statistics were performed in STATA v15.1. Results 122 residents (approximately 19% of eligible participants) responded. Approximately 40% reported no previous training in interpreter use, and 60% desired more training. Interpreter services are widely available but remain underused in a variety of clinical situations: interpreters are most often used during informed consent (98% ‘mostly’ or ‘always’), family meetings (97%), and history-taking (86%), and least often during physical examinations (41%) and bedside rounds (38%). Residents are more likely to use an interpreter if access is easy (97% ‘more likely’ or ‘likely’) or if there is extra time for the encounter (78%). Most residents (85%) felt they provide better care to patients who share their primary language (English or French), compared with families who prefer other languages. Conclusion Residents are more confident in their clinical and communication skills when working with families who share their primary language compared with NEFLP families, even when an interpreter is present. Our findings suggest that residents lack the training and confidence to provide equal care to families with varying language preferences. Paediatric training programs should develop curriculum content that not only targets safe and effective interpreter use, but also reviews non-spoken aspects of cultural awareness and safety.

Gender diversity training in Canadian paediatric postgraduate medical education: A needs assessment survey.

Evaluate the current state of postgraduate medical education on gender diversity in Canadian paediatric residency programs, exploring both resident and program director perceptions. Primary care providers are seeing more gender diverse children and youth in their offices, along with an exponential growth in referrals to Canadian specialty clinics and potential for significant mental health comorbidities. Gender-affirming support and management have been shown to improve overall outcomes. There is no mandatory curriculum on gender diversity for Canadian paediatric residency programs. Cross-sectional online surveys in English and French distributed to program directors (PDs) and paediatric residents in the 17 Canadian paediatric residency programs. Data were analyzed by descriptive statistics with 95% confidence intervals. Response rate was 88.2% from PDs and 24.5% from paediatric residents. Among PDs, 14.3% (95% confidence interval [CI]: 6.3, 22.3) reported a formal curriculum for gender diversity teaching. Sixty-four per cent (53.3, 75.2) of PDs estimated their residents received ≤ 2 hours teaching on gender diversity. Residents reported comfort levels ≤ 50% on specific topics. Among residents, 73.8% (67.9, 79.6) reported that mandatory time in a gender diversity clinic would be the most effective teaching tool while PDs favoured an online module (66.7% [58.2, 75.1]). Barriers to more teaching included lack of time in a busy curriculum. Over 90% of resident indicated that more teaching on gender diversity is required. Significant variability in education on gender diversity is seen amongst Canadian paediatric residency programs. Discussion regarding a formal paediatric curriculum on gender diversity is needed.

37 Choice of maintenance intravenous fluids: A survey of Canadian paediatric residents

37 Choice of maintenance intravenous fluids: A survey of Canadian paediatric residents

PREPARING FOR CBME: HOW OFTEN ARE FACULTY OBSERVING RESIDENTS?

Abstract BACKGROUND Transitioning to competency-based medical education (CBME) necessitates change in resident assessment. A greater frequency of resident observation will be required to adequately assess whether entrustable professional activities have been achieved. OBJECTIVES Characterize faculty and resident experiences of direct observation in a single Canadian Paediatric Residency program, pre-CBME implementation. Describe faculty and residents’ perceived barriers and incentives to participating in direct observation. DESIGN/METHODS Surveys were sent to faculty and residents asking for demographic information, the frequency of resident observation during an average 4-week rotation in several domains (taking a history, performing a physical examination, delivering a plan,...), perceived ideal frequency of observation, and factors influencing observation frequency. Descriptive data was analyzed. Institutional research ethics board approval was received. RESULTS The response rate was 54% (34/68 faculty and 16/25 residents). When asked the MAXIMUM frequency faculty observed a resident take a history, perform a physical examination, or deliver a plan, the median FACULTY reply was 1, 2, and 3, for outpatient settings and 0, 1, and 2, for inpatient settings, respectively. The median RESIDENT reply was 2, 4, and 10 for outpatient settings and 1, 2, and 20 for inpatient settings, respectively. When asked the MINIMUM frequency for each domain, the median FACULTY AND RESIDENT reply was 0, except for delivering a plan in the inpatient setting (median RESIDENT reply was 2). FACULTY and RESIDENT median replies for how frequently residents should ideally be observed for each domain were the same, 3–4, 3–4, and 5–6 times. 4% of faculty reported regularly scheduling observations, and 77% of residents regularly ask to be observed. The most common responses to barriers to observation were too many patients to see and that both faculty and residents were seeing patients at the same time. Most faculty and resident responders felt that observation frequency could be improved if they were scheduled at the start of the rotation, if faculty were provided a better tool for assessment, and if residents asked to be observed. CONCLUSION This study provides baseline data on how infrequent faculty observation of residents is occurring and at a frequency lower than what faculty and residents feel is necessary. The time needed for observation is felt to compete with clinical service demands, but better scheduling strategies and assessment tools may help increase the frequency of resident observation.

CONFIDENCE IN PERFORMING PEDIATRIC MUSCULOSKELETAL EXAMINATIONS IN CANADIAN PEDIATRIC RESIDENTS

BACKGROUND: Pediatric Musculoskeletal (pMSK) complaints are common and lead to important diagnostic considerations. However, international studies suggest that pediatric health providers (residents and consultants) are not confident in their pMSK assessments. At present, little is known about the confidence of Canadian pediatric residents in performing MSK examinations. OBJECTIVES: Our study evaluates the confidence of Canadian pediatric residents in performing pMSK examinations. In a subgroup of residents, we assessed changes in confidence after targeted training. DESIGN/METHODS: All pediatric residents enrolled in an accredited Canadian pediatric residency during the 2015-2016 academic year were invited to participate in an anonymous nationwide questionnaire. Survey respondents rated their confidence in performing pMSK examinations alone and in comparison to other body systems using a 10-point Likert scale. Pediatric residents enrolled in two centers participated in a one-day standardized pMSK examination workshop to learn the pediatric Gait, Arms, Legs, and Spine exam, a validated screening tool to facilitate pediatric joint examination; focused regional joint examinations were also reviewed. A follow-up confidence questionnaire was distributed immediately and six months’ after the intervention. RESULTS: 143 pediatric residents from 14 Canadian residency programs responded to the nationwide survey. Of the respondents, 56% (n=80) were previously taught the pMSK examination yet only 14% (n=20) reported routinely examining a child’s musculoskeletal system as part of a complete physical examination. The vast majority of respondents were “somewhat confident” with their pMSK examination, with an average confidence level of 4.6 (95%CI 4.3-4.9; 1=No confidence, 10=Very confident). Confidence was lower in comparison to cardiovascular, respiratory, and abdominal exams, but higher in comparison to peripheral nervous system and ophthalmologic examinations. In our subgroup analyses (n=50), we found an average increase in confidence by 2.1 points immediately after the intervention, from an initial confidence level of 4.9 (95% CI 4.5-5.4) to 7.1 (95% CI 6.6-7.5). This increase was sustained with a mean confidence rating of 6.9 (95% CI 6.1-7.7) six months post-workshop. The most frequently reported barriers to musculoskeletal examination confidence were limited practice (n=34,68%) and limited training opportunities (n=19,38%). CONCLUSION: Few Canadian pediatric trainees perform a pMSK examination as part of a complete examination, and self-rated confidence in pMSK examination was evaluated as “average” by the majority. We demonstrate that a standardized educational intervention can lead to increased confidence in performing pMSK examinations, but a decline in confidence is observed with time and without consistent practice.

CANADIAN PAEDIATRIC RESIDENT KNOWLEDGE AND PERCEPTION OF THEIR NATIONAL PAEDIATRIC PROFESSIONAL ORGANIZATION

BACKGROUND: The Canadian Paediatric Society (CPS) is the national paediatric professional organization representing over 3000 child and youth health care providers. There are currently 847 resident members of the CPS (including subspecialty fellows) in 2016. Residents are valued members of the CPS, and their engagement in the organization is a priority of the CPS. OBJECTIVES: The primary objectives of this study were to identify: 1. Resident knowledge of the CPS 2. Resident needs from the CPS 3. Further opportunities for engagement of residents within the CPS DESIGN/METHODS: A survey was developed by the principal authors (AR-L,RG-P,RS). The survey consisted of 23 questions with either closed-ended or free text responses. The survey was distributed, in English and French, via email link to 793 Canadian paediatric residents at every postgraduate training site in June 2016. All residents with an email address in the CPS membership database were included. Survey information was obtained through the use of an online electronic tool (Survey Monkey). All responses remained confidential, and were collated by the three authors (AR-L,RG-P,RS). Descriptive statistics were used to analyze the data. RESULTS: The survey response rate was 132/793 (17%). The majority of respondents (80.3%) were female. There was good representation across the provinces and from all levels of postgraduate training. Nearly all (96.2%) self-identified as CPS members. A minority (18/116; 15.5%) were current or past CPS representatives. Three quarters of respondents (73/101) felt that the role of the CPS for residents was educational, followed by roles in providing networking (29.7%) and advocacy (27.7%) opportunities. CPS resources are frequently used by residents; all respondents used its statements and practice points. Half of residents (58/115) have attended the CPS Annual Conference during their residency. Many respondents (33/116; 28.4%) have submitted an abstract to the CPS Annual Conference, while a smaller number have applied for a CPS advocacy grant (8.6%) or a CPS elective grant (5.2%). Most respondents were aware of National Residents’ Advocacy Week (71.6%) and the Residents’ Section Facebook group (44%), but less were aware of the resources on starting a community practice (13.8%) and the national locum listings (32%). Residents want the CPS to provide more educational resources (49.1%), specifically in the area of preparation for the paediatrics licensing exam (22.0%), as well as to provide career counselling (22.0%) through provision of job postings, specialty projections, and mentorship. Half of responding residents would like to be more involved in the CPS. CONCLUSION: Residents see the role of the CPS for residents as primarily educational, and CPS educational resources are well used by residents. Residents see the CPS assisting with their career decision-making by providing career counselling, job opportunities and a community for networking. A significant number of residents would like to be more involved in the CPS.

Wellness in Canadian paediatric residents and their program directors.

This study aimed to explore the prevalence of and identify risk factors for depression and burnout in paediatric residents and paediatric program directors (PDs) in Canada. Residents and PDs completed separate anonymous online surveys consisting of demographic questions, the Maslach Burnout Inventory and the Patient Health Questionnaire-2, which screens for risk of depression. A total of 166 paediatric residents completed the survey representing 14/17 Canadian paediatric residency programs. Participants were 74% female. Twenty-four (14%) were at risk of depression and 69 (42%) met criteria for burnout. Burnout was associated with year of residency (P=0.03), with third year residents at highest risk. Residents who reported unhelpful wellness curricula were at risk of burnout (81.3%) compared with those with no wellness curricula (51.1%) or curricula reported as helpful (29.1%, P=0.01). More than 79% of residents at risk of depression also met criteria for burnout (P=0.01). No associations were identified for risk of depression.Seventeen of 21 Canadian PDs completed the survey. No PDs were identified as at risk for depression. Five PDs (29%) met criteria for burnout. Paediatric PDs in Canada have relatively low rates of burnout and depression. In contrast, a large number of Canadian paediatric residents met criteria for burnout. Residents in programs with wellness curricula described as helpful are at lowest risk of burnout. Future research should include identifying features that define helpful wellness curricula and exploring interventions to help residents at risk of burnout and depression.

The training paths and practice patterns of Canadian paediatric residency graduates, 2004–2010

The Paediatric Chairs of Canada have been proactive in workforce planning, anticipating paediatric job opportunities in academic centres. To complement this, it is important to characterize the practice profiles of paediatricians exiting training, including those working outside of tertiary care centres. To describe the training paths and the practice patterns of Canadian paediatric residency graduates. A survey was completed in 2010 to 2011 by Canadian program directors regarding residents completing core paediatrics training between 2004 and 2010. Data collection included training path after completing core paediatrics training and practice type after graduation. Of 699 residents completing their core training in paediatrics, training path data were available for 685 (98%). Overall, 430 (63%) residents completed subspecialty training while 255 (37%) completed general paediatrics training only. There was a significant increase in subspecialty training, from 59% in earlier graduates (2004 to 2007) to 67% in later graduates (2008 to 2010) (P=0.037). Practice pattern data after completion of training were available for 245 general paediatricians and 205 subspecialists. Sixty-nine percent of general paediatricians were community based while 85% of subspecialists were hospital based in tertiary or quaternary centres. Of all residents currently in practice, only 36 (8%) were working in rural, remote or underserviced areas. Almost two-thirds of recent Canadian paediatric graduates pursued subspecialty training. There was a significant increase in the frequency of subspecialty training among later-year graduates. Few graduates are practicing in rural or underserviced areas. Further studies are needed to determine whether these trends continue and their impact on the future paediatric workforce in Canada.

Stress and the pediatric dental resident: Contributing factors and coping mechanisms

Aims: The purpose of this study was to determine self-reported stress levels and coping mechanisms utilized by current pediatric dental residents to generate recommendations to program directors. Subjects and Methods: A 26-question online survey was completed by 250 current United States and Canadian pediatric dental residents and summarized using frequencies and percentages. Statistical Analysis Used: Relationships between various factors and stress levels were evaluated separately using Mantel-Haenszel Chi-square tests for ordered categorical responses. Relationships between various factors and depressive symptoms were evaluated separately using Pearson Chi-square tests. All test were performed with a significance level of P = 0.05. Results: Forty percent of respondents report their stress level as high or medium-high. Stress levels were individually related to gender, academic demands, clinical demands, sleep factors, and hours per week devoted to the residency program. The most common coping mechanisms employed include exercise or sports (68%), television (66%), and socializing (62%). Conclusions: Prospective applicants should recognize the potential for additional stressors that present when one enters into a postgraduate training program; current residents should monitor their stress levels and employ healthy coping mechanisms. Program directors should be cognizant of lifestyle burdens encountered as a resident, evaluate stress levels at timely intervals, and refer to appropriate health and wellness assistance programs as necessary.

Pediatric fractures - an educational needs assessment of Canadian pediatric emergency medicine residents.

ObjectivesTo determine the gaps in knowledge of Canadian pediatric emergency medicine residents with regards to acute fracture identification and management. Due to their predominantly medical prior training, fractures may be an area of weakness requiring a specific curriculum to meet their needs.MethodsA questionnaire was developed examining comfort level and performance on knowledge based questions of trainees in the following areas: interpreting musculoskeletal X-rays; independently managing pediatric fractures, physical examination techniques, applied knowledge of fracture management, and normal development of the bony anatomy. Using modified Dillman technique the instrument was distributed to pediatric emergency medicine residents at seven Canadian sites.ResultsOut of 43 potential respondents, 22 (51%) responded. Of respondents, mean comfort with X-ray interpretation was 69 (62–76 95% confidence interval [CI]) while mean comfort with fracture management was only 53 (45–63 95% CI); mean comfort with physical exam of shoulder 60 (53–68 95% CI) and knee 69 (62–76 95% CI) was low. Less than half of respondents (47%; 95% CI 26%–69%) could accurately identify normal wrist development, correctly manage a supracondylar fracture (39%; 95% CI 20%–61%), or identify a medial epicondyle fracture (44%; 95% CI 24%–66%). Comfort with neurovascular status of the upper (mean 82; 95% CI 75–89) and lower limb (mean 81; 95% CI 74–87) was high.InterpretationThere are significant gaps in knowledge of physical exam techniques, fracture identification and management among pediatric emergency medicine trainees. A change in our current teaching methods is required to meet this need.

The Training and Career Paths of Canadian Paediatric Residents, 2004–2010

Canadian pediatric residents usually pursue training in general pediatrics or subspecialty pediatrics. Graduates can work in community-based settings, hospital-based settings, or a combination thereof. Furthermore, new graduates may work in large urban or rural/remote centers. To date, no study has profiled the training and career paths of Canadian pediatric residents. The goal of this study was to profile the training and career paths …

Utilization of clinical practice guidelines: a survey of Canadian pediatric physicians

Background: It is not clear how physicians currently use clinical practice guidelines (CPGs).Objectives: The objective was to describe how Canadian pediatric residents and pediatricians use CPGs and to identify barriers to CPG use.Methods: Pediatric emergency physicians and general pediatricians in Edmonton and Ottawa and all Canadian pediatric residents were surveyed regarding patterns of use for CPGs and barriers to use. Results: Response rate was 178/847 (21%). The majority of responding residents (62%), emergency physicians (54%) and general pediatricians teaching more than 6 weeks annually on a clinical teaching unit (CTU) use CPGs at least monthly (55%) with less frequent use by pediatricians who teach 1 to 6 weeks on CTU (14%) or rarely/never teach on CTU (21%) (p<0.001). Canadian physicians are more likely to read Canadian Paediatric Society guidelines when they are published versus referring to them later when dealing with clinical problems while the opposite appears to be true for American Academy of Pediatrics guidelines. The most common barrier to use of guidelines is forgetting that a guideline exists for a specific problem. The majority of physicians access CPGs electronically and support development of web based tools to improve accessibility.Conclusions: Almost all pediatric residents, pediatric emergency physicians and general pediatricians sometimes refer to CPGs. General pediatricians teaching less than 6 weeks per year on CTUs are an important target population, as most use CPGs infrequently. Prompts that CPGs exist and accessible online summaries of CPGs appear to have potential for overcoming the barriers to use.

Procedural skills in paediatric residency: Re-evaluating the competencies.

The Royal College of Physicians and Surgeons of Canada (RCPSC) sets objectives for residency training, including many skills that may not be commonly performed in practice. To describe attitudes of residents enrolled in Canadian paediatric residency programs toward procedural skills training, including perception of importance and perceived proficiency of the RCPSC-required procedures. An anonymous electronic survey was distributed to all senior residents enrolled in Canadian paediatric residencies, using a five-point Likert scale to address procedural importance and corresponding proficiency. Data were analyzed using descriptive statistics, with Pearson correlation coefficients used to describe relationships among variables. A total of 68 residents responded. Fifteen skills had a mean importance ≥4 (very or extremely important) and five skills had a mean rating <3 (somewhat or not important). Residents believed they were extremely or very proficient (mean rating ≥4) for three skills (bag-mask ventilation, lumbar puncture and chest x-ray interpretation). They reported 23 procedures for which they felt somewhat to not proficient (mean <3). The correlation between importance and proficiency was high (Pearson's correlation coefficient = 0.87). However, proficiency was significantly lower than importance (P<0.05) for the majority of procedures (88%). The largest gaps between importance and proficiency were observed for chest tube insertion, gathering evidence of child maltreatment, defibrillation and intraosseous insertion. Many, but not all, RCPSC-required procedures are believed to be important. Residents do not believe that they are adequately proficient in many of these procedures. Skills with the greatest gap between importance and proficiency may be targets for curricular interventions.

Resident Perspectives on Global Health Electives in Canadian Paediatric Residency Programs

Resident Perspectives on Global Health Electives in Canadian Paediatric Residency Programs

Program Directors' Perspectives on global Health Elective Preparation in Canadian Paediatric Residency Programs

Program Directors' Perspectives on global Health Elective Preparation in Canadian Paediatric Residency Programs

The experience of paediatric residents participating in a child protection rotation: A qualitative study

Practitioners working in the field of child maltreatment are at risk for vicarious traumatization. For Canadian paediatric residents, exposure to child abuse during training is limited. To explore how paediatric residents experience a mandatory rotation within a hospital-based child protection team (CPT) from an emotional and professional development standpoint. Eight paediatric residents were interviewed following their CPT rotation and transcripts were analyzed using a phenomenological approach. Exemplar quotes were then highlighted. FOUR MAJOR THEMES WERE IDENTIFIED: baseline experiences; individual resident factors; intrinsic CPT rotation factors; and overall rotation assessment. The themes and their subthemes were used to inform a conceptual model of residents' experiences. The knowledge provided through residents' accounts can be applied to strengthen future educational opportunities in the field of child maltreatment and offer insight to help guide the development of support systems and debriefing processes that are important in this challenging field.

Global child health education in Canadian paediatric residency programs

Globalisation has led to significant changes in health care, yet medical education remains domestically focused. The majority of the world's children live in developing countries, and education related to global child health is important for paediatric residents. Chief residents and program directors from the 16 Canadian paediatric training programs were surveyed using a questionnaire regarding global child health training program content, electives, attitudes and perceptions towards global child health. No programs had a formalised global health curriculum. All program directors and chief residents reported that programs offer global child health sessions, but 50% of the programs did not address six out of twelve of the content areas including topics such as refugee health and international adoption. All program directors agreed global child health understanding is important for paediatric trainees; 83% agreed more emphasis should be placed on this during post-graduate training. A formalised global child health curriculum is lacking for Canadian paediatric residents: Program directors are willing to integrate global child health training modules into their post-graduate training programs.

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

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. 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. 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. 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). 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.

Global Child Health Education in Canadian Paediatric Residency Programs

Global Child Health Education in Canadian Paediatric Residency Programs