Third-year Pediatric Residents Research Articles

Pediatric Residents’ and Continuity Clinic Preceptors’ Perceptions of the Effects of Restricted Work Hours on Their Learning Relationship

The effects of the Work Hour Standard (WHS) on continuity of care and quality of education has stimulated much discussion, yet little is known about how it affects the resident-continuity clinic preceptor (CCP) dyad, the only longitudinal learning relationship in pediatric residency. This case study explored residents' and CCPs' perceptions of the effects of restricted work hours on their learning relationship. Direct observation of third-year pediatric residents (n = 10) and their CCPs (n = 10) was carried out in continuity clinic (CC) for 5 months; both groups attended clinic before and after the WHS. Semistructured, audiotaped interviews were conducted with residents before and after observation, and with CCPs after resident data were collected. Data from interview transcripts and observational notes were analyzed for major themes. To comply with the WHS, postcall clinic was eliminated and residents were rescheduled to another afternoon CC. The consequence of eliminating postcall clinic, disruption in the resident-CCP relationship, was perceived differently by residents and CCPs. From the residents' perspective, rescheduling CC in response to the WHS benefited their learning because it exposed them to different CCPs with different practice styles. From the CCPs' perspective, rescheduling CC frustrated their efforts to be learner-centered teachers and effective mentors. Intended changes to limit excessive work hours had unintended effects that were viewed more favorably by residents than by CCPs. Understanding the shared and different perspectives of residents and preceptors regarding WHS-related changes in CC extends the discussion of the effect of restricted work hours.

Learning About Systems-Based Practice in the Informal Curriculum: A Case Study in an Academic Pediatric Continuity Clinic

Pediatric residents learn about systems-based practice (SBP) explicitly in the formal curriculum and implicitly in the informal curriculum as they engage in practice alongside physician faculty. Recent studies describe innovative ways to address SBP in the formal curriculum for SBP, but the informal curriculum has not been explored. We examined what, and how, third-year pediatric residents learn about SBP in the informal curriculum at one continuity clinic, and to consider how this learning aligns with the formal curriculum. A case study involving 10 third-year pediatric residents and 10 continuity preceptors was conducted at one continuity clinic, housed in a community-based, pediatric primary care center. Data were derived from 5 months (100 hours) of direct observation in the precepting room at the case clinic, semistructured interviews with residents (before and after observation) and with preceptors (after observation). Interview transcripts and notes from observation were inductively coded and analyzed for major themes. Two themes emerged in the informal curriculum. Residents perceived "our system," the academic health system in which they trained and practiced as separate and distinct from the "real system," the larger, societal context of health care. Residents also understood SBP as a commitment to helping individual patients and families navigate the complexities of "our system," dealing with issues that concerned them. Residents learn important lessons about SBP in the informal curriculum in continuity clinic. These lessons may reinforce some elements of the competency-based formal curriculum for SBP, but challenge others.

Learning Behind the Scenes: Perceptions and Observations of Role Modeling in Pediatric Residents’ Continuity Experience

Little is known about what residents learn from "everyday" physician role models, who, in the course of their ordinary work, serve as real-life examples of residents' future roles. The purpose of this research was to analyze what and how pediatric residents learn through role modeling during their continuity experience. We conducted a case study of 10 third-year pediatric residents and their 10 continuity clinic preceptors (CCP) in a community-based continuity clinic. Data were derived from 5 months (100 hours) of direct observation in clinic; semistructured interviews with residents before and after observation; and semistructured interviews with CCPs after resident data were collected. Interview transcripts and notes from observation were inductively coded and thematically analyzed. From the residents' perspective, role modeling was an implicit and intentional learning strategy that was linked to routine clinical practice in continuity clinic. Residents learned, through modeling their CCPs, "how to talk" and "how to think things through." Residents did not directly report modeling professional behavior. For residents, learning through modeling was not contingent on CCPs' awareness of being a role model. Role modeling is a nuanced, deliberate learning strategy that provides pediatric residents with templates for interpersonal communication and clinical decision making that have both immediate and long-term relevance. Understanding residents' perspective on role modeling, and how it aligns with their CCPs' perspective, presents opportunities for improving residents' learning experiences, faculty development, and future research.

Conversations With Parents of Medically Ill Children: A Study of Interactions Between Medical Students and Parents and Pediatric Residents and Parents in the Clinical Setting

Background: The traditional remedies applied by medical schools to the perennial problem of teaching "caring competence" have been unsuccessful. Purpose: Our purpose was to design and evaluate a simple and effective method for helping students maintain affective contact with their patients. Methods: Third-year medical students and pediatric residents were given the opportunity to talk informally with parents of medically ill children and reflect on the value of this experience for their learning. Trainees' opinions of the experience were measured with focus groups and a questionnaire. Results: Trainees were delighted with the experience, particularly with the following aspects: the opportunity to hear a personally relevant story told in a sincere manner, the realization that they could have an authentic interaction "even" in a medical setting, and the usefulness of the information they derived from the conversation. Conclusions: We concluded that something unique to the conversational experience has educational value.

Care to underserved children: Residents' attitudes and experiences.

To examine: 1) the relationship between residents' responses toward caring for underserved children and families during residency and their perceptions of their continuity clinic experience; and 2) which characteristics are related to continuing to care for the underserved after completion of training. Cross-sectional descriptive study. A 49-item questionnaire was mailed to 210 third-year pediatric residents at 12 urban training programs in the Northeast in May 1995. Information was collected about residents' emotional responses toward caring for underserved families, their assessments of clinic operations, their sense of effectiveness in caring for underserved patients in continuity clinic, preresidency experiences with the underserved, and their intent to care for the underserved after training. Of 210 surveys mailed, 71% were returned. Thirty-six percent of residents planned to pursue a career in primary care, 53% did not, and 11% did not answer or were planning a year as chief resident. Fifty-seven percent of all residents planned to devote a portion of their practice toward caring for the underserved after training. Residents whose emotional responses toward caring for the underserved included: 1) not worrying that they had become numb to children's psychosocial difficulties, 2) not feeling angry with how families cared for their children, and 3) feeling more empathy with the underserved had significantly higher mean scores on both their assessment of clinic operations and their sense of effectiveness. The only demographic characteristic associated with a greater sense of effectiveness was being black. To better characterize which residents planned to care for the underserved after training, we examined a subsample of 46 residents who recalled an interest in caring for the underserved during residency training and who were pursuing a career in primary care. Residents that did not recall an interest in caring for the underserved at the onset of residency training were unlikely to have plans to care for the underserved after the completion of training. Within this group residents who planned to care for the underserved after training differed significantly from residents who did not plan to continue this work by feeling a greater sense of effectiveness in clinic, feeling less worried about becoming numb, and having greater empathy for underserved families. There are a number of identifiable emotional responses residents develop toward caring for the underserved that relate to their perceptions of continuity clinic and whether a resident chooses to continue to care for the underserved after training.

A valid and reliable measure of physician immunization-relevant knowledge, attitudes, and practices 670

Background: Despite improving trends, immunization rates among U.S. preschool children are still suboptimal. It has been recently recognized that healthcare providers play a critical role in undervaccination. Despite this fact, few reliable and validated instruments to assess immunization knowledge, attitudes, and practices have been developed for use among healthcare providers. In a cross-sectional study involving groups of 38 general pediatricians, 46 subspecialty pediatricians, 11 third-year pediatric residents, and 33 first-year pediatric and family medicine residents an instrument was developed to evaluate provider knowledge, attitudes, and practices.

Teaching residents to teach. An instructional program for training pediatric residents to precept third-year medical students in the ambulatory clinic.

To provide second- and third-year pediatric residents with practical teaching skills for precepting third-year medical students in the outpatient clinic. Educational intervention with 3-month follow-up of participants. University teaching hospital. Second- and third-year pediatric residents. A curriculum for a half-day workshop to provide residents with 6 key clinical teaching skills. Residents participated in the workshop and then were observed by trained faculty as they precepted third-year medical students in the pediatric clinic. Direct observation of resident-student precepting encounters, noting the presence or absence of their use of clinical teaching skills taught in the workshop. Twenty-one of 23 pediatric residents participated in the workshop. Observation of 56 resident teaching encounters before and after the workshop showed that the residents improved their clinical teaching skills. Residents valued the workshop, and many suggested it should also be considered for faculty development. Residents can be taught clinical teaching skills in a half-day workshop. These skills also are applicable in various clinical venues. With the increasing interest in using community-based primary care physicians for student and resident education, this curriculum is well suited for training practicing clinicians to teach in their own practice sites.

Residents' self-assessed skills in providing sexuality-related care to teenagers.

To assess pediatric residents' self-reported skills and satisfaction with providing sexuality-related health care to teenagers and to examine differences by resident and patient gender. Cross-sectional survey. Forty second-year (PGY2) and 17 third-year (PGY3) pediatric residents at one training program who completed a self-administered questionnaire. Residents rated their skills with taking a history from, performing a physical examination on, developing a diagnosis for, and counseling both male and female teenagers. Skills with providing health care to male and female teenagers were assessed separately. Scales were constructed for skills with performing a physical examination and providing a diagnosis and counseling. Residents also rated their satisfaction with providing health care to male and female teenagers. Skills and satisfaction with providing health care to male vs female teenagers were analyzed. Female residents rated their skills with providing health care to male teenagers significantly lower than their skills with providing health care to female teenagers as follows: taking a history of pubertal development (PGY2, P = .001; PGY3, P = .02), taking a sexual history (PGY2, P = .004), asking about sexual preference (PGY2, P = .02), examination and diagnosis scale (PGY2, P < .001; PGY3, P = .008), and counseling scale (PGY2, P = .003). For male residents, there were no significant differences in skills with providing health care to male vs female teenagers. Second-year, but not third-year, female residents reported significantly lower (P < .005) satisfaction with providing health care to male vs female teenagers. Among female residents, discrepancies were found when comparing self-assessed competencies and, for PGY2 residents, level of satisfaction with providing health care to male vs female patients. If other research confirms these findings, educational interventions related to sexuality-related health care for teenagers should be designed with consideration to gender-specific learner needs.

Effect of an adolescent medicine rotation on medical students and pediatric residents

This study evaluated the effects of an adolescent medicine rotation on the attitudes and skills in the care of adolescents of third-year pediatric residents and medical students. Competence, comfort, and prior training in four areas were assessed by a self-evaluation questionnaire. Ratings were made at the start of the year, prerotation, and post a four- to six-week rotation. Residents not taking the rotation were rated at the beginning and end of the year. In addition, pelvic-examination skills were assessed by the clinic nurse and by the patients during the first and last week of the rotation. There were no significant changes in those not taking the rotation. In those residents taking the rotation, there was no change from beginning of year to prerotation, but there were significant changes after the rotation. Only those residents taking the rotation indicated an increase in liking adolescents. Pelvic examination skills were rated significantly higher during the last week of the rotation by the nurse and patients. A one-year follow-up study continued to show significantly higher scores in those residents taking the rotation. An adolescent medicine elective may significantly improve medical students' and residents' self-assessed levels of competence, comfort, and training in adolescent health care and pelvic examination skills.

Death and the Pediatric House Officer Revisited

Thirty-six third-year pediatric residents at four Western university training programs were interviewed individually and retrospectively about the magnitude of their clinical experience in managing the treatment of chronically ill and dying children, as well as the psychosocial educational curriculum of their training program as it pertained to these experiences. The residents managed an average of 35 dying children during their first 2 1/2 years of pediatric residency. They imparted the news of a potentially fatal disease to an average of 33 families during this same time span. There was a disparity between the magnitude of the clinical experience and the time and emphasis on these issues in the residency curriculum. The implications of these findings for an improved educational curriculum in the psychosocial care of dying children are discussed.