Specialty impact on residents’ perceived quality of life, stress, and job satisfaction: a comparative study

Purpose@#Specialty choice in residency training has a significant impact on an individual’s career and satisfaction, as well as the supply-demand imbalance in the healthcare system. The current study aimed to investigate the quality of life (QOL), stress, self-confidence, and job satisfaction of residents, and to explore factors associated with such variables, including postgraduate year, sex, and especially specialty, through a cross-sectional survey. @*Methods@#An online survey was administered to residents at 2 affiliated teaching hospitals. The survey had a total of 46 items encompassing overall residency life such as workload, QOL, stress, confidence, relationship, harassment, and satisfaction. Related survey items were then reconstructed into 4 key categories through exploratory factor analysis for comparison according to group classification. @*Results@#The weekly work hours of residents in vital and other specialties were similar, but residents in vital specialties had significantly more on-call days per month. Residents in vital specialties had significantly lower scores for QOL and satisfaction. Specifically, vital-surgical residents had significantly lower QOL scores and higher stress scores than the other specialty groups. Satisfaction scores were also lowest among vital-surgical residents, with a marginal difference from vital-medical, and a significant difference from other-surgical residents. Female residents had significantly lower satisfaction scores than their male counterparts. @*Conclusion@#Residents in vital specialties, particularly vital-surgical specialties, experience significantly worse working conditions across multiple dimensions. It is necessary to improve not only the quantity but also the quality of the system in terms of resource allocation and prioritization.

Educational implications of assessing learning outcomes with multiple choice questions and short essay questions / 한국의학교육

Purpose@#This study investigates the characteristics of different item types to assess learning outcomes and explore the educational implications that can be obtained from the results of learning outcome assessments. @*Methods@#Forty-five second-year premedical students participated in this study. Multiple choice question (MCQ) and short essay question (SEQ) scores and pass rates for 10 learning outcomes were analyzed. Descriptive statistics and correlation analysis were used to analyze the data. @*Results@#The correlation analysis indicated that there was a significant correlation between SEQs and pass rate but there was no significant correlation between MCQs and pass rate. Some students with identical scores on the MCQs had different scores on the SEQs or on the learning outcomes. @*Conclusion@#This study showed that students’ achievement of learning outcomes can be assessed using various types of questions in outcome-based education.

Development an instrument assessing residents' attitude towards professionalism lapses in training / 한국의학교육

PURPOSE: Medical professionalism is a fundamental competency for all physicians and continuous development of professionalism during residency training is crucial. The purpose of this study was to develop an instrument assessing residents' attitudes toward unprofessional behaviors. METHODS: A questionnaire survey was conducted in cooperation with the Korea Resident Association from May to July 2013. A total of 317 residents from seven university-affiliated hospitals in South Korea participated in the survey. RESULTS: In the exploratory factor analysis, seven factors were extracted from the data; factor loadings of the 44 items ranged between 0.40 and 0.89. Through iterative discussion, three items below 0.45 were deleted and one additional item was removed due to its irrelevance. Twelve items included in Factor 1 were divided into two different categories. A final version of the questionnaire containing 40 items in eight categories was assessed using confirmatory factor analysis. It was deemed to have a good fit; the root mean square error of approximation and comparative fit index were 0.07 and 0.9, respectively. The reliability (Cronbach's α) of the inventory was 0.97. CONCLUSION: The items of this instrument encompass a broad range of residents' behaviors in clinical practice, research, and publication. In addition, it includes some types of misconduct that can be considered unique features of the authors' cultural backgrounds. We recommend this instrument as an assessment tool to diagnose residents' perceptions and attitudes towards professionalism lapses and to provide insight regarding potential improvement in professionalism education.

Needs assessment of a core curriculum for residency training / 한국의학교육

PURPOSE: The core curriculum in graduate medical education (GME) is an educational program that covers the minimum body of knowledge and skills that is required of all residents, regardless of their specialty. This study examined the opinions of stakeholders in GME regarding the core curriculum. METHODS: A questionnaire was administered at three tertiary hospitals that were affiliated with one university; 192 residents and 61 faculty members and attending physicians participated in the survey. The questionnaire comprised six items on physician competency and the needs for a core curriculum. Questions on subjects or topics and adequate training years for each topics were asked only to residents. RESULTS: Most residents (78.6%) and faculty members (86.9%) chose "medical expertise" as the "doctor's role in the 21st century." In contrast, communicator, manager, and collaborator were recognized by less than 30% of all participants. Most residents (74.1%) responded that a core curriculum is "necessary but not feasible," whereas 68.3% of faculty members answered that it is "absolutely needed." Regarding subjects that should be included in the core curriculum, residents and faculty members had disparate preferences-residents preferred more "management of a private clinic" and "financial management," whereas faculty members desired "medical ethics" and "communication skills." CONCLUSION: Residents and faculty members agree that residents should develop a wide range of competencies in their training. However, the perception of the feasibility and opinions on the contents of the core curriculum differed between groups. Further studies with larger samples should be conducted to define the roles and professional competencies of physicians and the needs for a core curriculum in GME.

Pertussis Accompanying Recent Mycoplasma Infection in a 10-Year-Old Girl / 감염과화학요법

Recently, the incidence of pertussis has been increasing; however, reports on mixed infection of pertussis with other respiratory pathogens are rare in highly immunized populations. We report the case of a 10-year-old girl who presented with cough, post-tussive emesis, and fever. She was subsequently diagnosed with bronchopneumonia. Although she had received five doses of diphtheria-tetanus-acellular pertussis vaccine, polymerase chain reaction of her nasopharyngeal aspirate confirmed Bordetella pertussis infection. In addition, serologic testing for Mycoplasma pneumoniae was also positive. The patient was treated with roxithromycin without any complications. This is the first report of mixed B. pertussis and M. pneumoniae infection in Korea. To avoid under-diagnosis, pertussis should be considered in patients with chronic cough even when other respiratory pathogens have been documented.

The Immunogenicity and Safety of the Live-attenuated SA 14-14-2 Japanese Encephalitis Vaccine Given with a Two-dose Primary Schedule in Children

Effective and tolerable vaccination is an essential strategy to prevent Japanese encephalitis (JE) in endemic areas. Although the live attenuated SA 14-14-2 JE vaccine (LAJEV) has been widely used since its introduction, the systemic data of LAJEV was very rarely available in Korea. We conducted the open-label, prospective cohort study to assess the immunogenicity and safety of this vaccine. Ninety subjects were enrolled, and LAJEV in a 2-dose primary series was given with a 12-month interval. Neutralizing antibody titers were measured before and after each vaccination, and active monitoring for adverse events was performed. After the first dose, 91.1% of subjects had seroprotection with a geometric mean titer (GMT) of 40.9. Seroprotection rate after the second dose was 97%, and GMT showed an increase of 6.5-fold. Most adverse events following immunization were self-limited, and no serious adverse events were reported until 42 days after each dose. The 2-dose administration of LAJEV in the primary immunization schedule appeared to be highly immunogenic and safe.

Development of a code of professional conduct for medical students and residents / 한국의학교육

PURPOSE: The purpose of this study was to describe the development of a code of professional conduct that should be practiced by medical students and residents. METHODS: The content of a draft version of a code of professional conduct was generated through extensive literature reviews and the results of surveys that were administered to students and residents. The content validity for the draft version was reviewed by an expert panel: five experts in medical ethics and eight specialists in medical education. The survey was distributed as an email questionnaire and included closed-ended items and open comments. SPSS for Windows version 12.0 (SPSS Inc.) was used for the analysis. RESULTS: After analyzing the experts' reviews and holding a reiterative discussion, we developed the final version of a code of conduct for professional behavior. It consists of nine categories and 44 items for students and 44 items for residents. The nine categories were academic integrity, responsibility during clerkship or hospital work, endeavor to improve clinical competency, respect for patients and keeping confidentiality, honesty in patient care, boundary issues and conflicts of interests, impaired physician behaviors, respect for others, and research ethics. CONCLUSION: Because our code of conduct for professional behaviors cannot extensively include all aspects of medical professionalism, we focused on behaviors that can be used to monitor and prevent misconduct by medical learners. Further studies and discourse among stakeholders should be performed to develop a national consensus statement or code of conduct to reinforce professionalism for learners in medicine.

Development of an inventory assessing medical students' attitudes towards academic misconduct / 한국의학교육

PURPOSE: Identifying medical students' perceptions of and experiences with unprofessional behavior in school can help them develop and maintain higher standards of professional ethics. The aim of this study was to develop an instrument that assesses medical students' attitudes toward academic misconduct. METHODS: A draft version of the questionnaire form was developed, based on an extensive literature review and iterative discussions. The validity of the content of this draft form was evaluated by medical students, physicians, and education specialists. A total of 803 medical students answered the questionnaire. Exploratory factor analysis was performed using principal axis factoring and Varimax rotation. A confirmatory factor analysis was also conducted by root mean square error of approximation (RMSEA) and comparative fit index (CFI). The internal consistency of the scales was calculated using the Cronbach alpha statistic. RESULTS: The exploratory factor analysis generated 6 factors with 29 items: scientific misconduct (8 items); irresponsibility in the class (6 items); disrespectful behavior in patient care (5 items); dishonesty in clerkship tasks (4 items); free-riding on group assignments (4 items); and irresponsibility during clerkship (2 items). After adding a single item that addressed cheating on examinations, a 30-item inventory was developed. A confirmatory factor analysis demonstrated a favorable RMSEA (0.082) and reasonable fit (CFI, 0.844). The coefficient alpha for each factor varied between 0.80 and 0.90. CONCLUSION: Our instrument is useful in identifying students' ethical standards with regard to academics and examining the prevalence of unprofessional behavior in medical students.

Nasopharyngeal Carriage Rate and Serotypes of Streptococcus pneumoniae and Antimicrobial Susceptibility in Healthy Korean Children Younger than 5 Years Old: Focus on Influence of Pneumococcal Conjugate Vaccination / 감염과화학요법

BACKGROUND: Even after pneumococcal vaccination introduction, Streptococcus pneumoniae (pneumoccocus) is still an important cause of respiratory and invasive severe infection. Pneumococcus is resided in nasal mucosa and local or systemic infection begins with the nasal mucosa damage. We studied the indirect effect of pneumococcal conjugate vaccine (PCV) on pneumococcal nasopharyngeal carriage rates, serotypes and antimicrobial susceptibility between vaccinate and non-vaccinated children. MATERIALS AND METHODS: From January 2010 to October 2010, 379 healthy children under 5 years old from three university hospitals were recruited. Fully vaccinated children over 3 time doses of PCV and children with no vaccination history of PCV were enrolled, and nasopharyngeal aspirations were obtained from these children. Serotypes using multibead serotyping assay with multiplex PCR and antimicrobial susceptibility was analyzed. Antimicrobial susceptibilities were determined by the CLIS guideline. RESULTS: Two hundred seventy six children were received pneumococcal vaccination while 103 were not. 137 pneumococci were isolated from nasopharyngeal aspiration specimens. Nasal carriage rate was significantly low in vaccinated group (P-value; 0.001). Nasopharyngeal carriage rate was 28.6% (79/276) in vaccinate group and 56.3% (58/103) in non-vaccinated group. Among those vaccinated group, 13.0% (36/276) of the serotypes were vaccine or vaccine related type with the most common type 19F. In contrast, 31.1% (32/103) of the serotypes in non vaccinated group were vaccine or vaccine related type with the most common type 6A. The resistant rate of penicillin was 90.5%. For antimicrobial susceptibility, amoxicillin and amoxicillin/clavulanate showed high susceptibility (73.0%), but 19F and 19A serotypes were all resistant against amoxicillin. CONCLUSIONS: High nasopharyngeal carriage rate in non vaccinated group corresponded to the result of past study. However, 19F and 19A still came up as problematic serotypes with a high carriage rate and antimicrobial resistance in both vaccinated and non vaccinated groups. Also, this study showed that the resistance rate of primary oral antimicrobial agents was increased in compared to past. For solving these problems, the selective antimicrobial use with establishment of high dose amoxicillin/clavulanate regimen and active PCV immunization should be needed. Furthermore, pneumococcal carriage and serotype study concerning with antimicrobial susceptibility should be conducted in the future in 10 or 13-valent PCV received children.

Acute Acalculous Cholecystitis with Bacteremia Caused by Streptococcus anginosus Following Dental Procedure in a Previously Healthy Adolescent / 소아감염

Streptococcus anginosus is a member of Streptococcus milleri group, and is found in the oral mucosa, respiratory tract, and gastrointestinal tract as normal flora. It can develop into a disease in patients with deteriorating clinical condition or with clinical risk factors. A previously healthy 15-year-old boy was admitted due to fever, abdominal discomfort and vomiting which lasted for 7 days. He had a history of dental procedure 1 day before the development of fever. He was diagnosed with acute acalculous cholecystitis based on the clinical, laboratory, and imaging finding, and S. anginosus was isolated from the blood culture. The patient was successfully treated with antibiotic therapy.

A Case of Therapy of Aerosolized Ribavirin in a Leukemia Infant with RSV Infection / 소아감염

Respiratory syncytial virus (RSV) is the major cause of lower respiratory tract infection in infants. Life-threatening RSV infection is often reported in young children and immunocompromised hosts. Since there is no report on ribavirin therapy for RSV pneumonia in pediatric cancer patients in Korea, we report one case of RSV pneumonia that developed in an infant with acute lymphoblastic leukemia (ALL). Despite administration of oral ribavirin and intravenous immunoglobulin, the patient's respiratory distress worsened and admission to an intensive care unit was necessary. Chest x-ray showed multifocal consolidation, pneumothorax, and pneumomediastinum. Treatment with aerosolized ribavirin led to significant clinical improvement. The role of aerosolized ribavirin is still controversial, but it might have a therapeutic potential for severe RSV pneumonia in children with leukemia.

Assessment of Serologic Immunity to Diphtheria-Tetanus-Pertussis After Treatment of Korean Pediatric Hematology and Oncology Patients

The aim of this study was to investigate the diphtheria-tetanus-pertussis antibody titers after antineoplastic treatment and to suggest an appropriate vaccination approach for pediatric hemato-oncologic patients. A total of 146 children with either malignancy in remission after cessation of therapy or bone marrow failure were recruited. All children had received routine immunization including diphtheria-tetanus-acellular pertussis vaccination before diagnosis of cancer. The serologic immunity to diphtheria, tetanus and pertussis was classified as: completely protective, partially protective, or non-protective. Non-protective serum antibody titer for diphtheria, tetanus and pertussis was detected in 6.2%, 11.6%, and 62.3% of patients, respectively, and partial protective serum antibody titer for diphtheria, tetanus and pertussis was seen in 37%, 28.1%, and 8.9% of patients. There was no significant correlation between the severity of immune defect and age, gender or underlying disease. Revaccination after antineoplastic therapy showed significantly higher levels of antibody for each vaccine antigen. Our data indicates that a large proportion of children lacked protective serum concentrations of antibodies against diphtheria, tetanus, and pertussis. This suggests that reimmunization of these patients is necessary after completion of antineoplastic treatment. Also, prospective studies should be undertaken with the aim of devising a common strategy of revaccination.

Severe Osteomyelitis as a Complication of Tokyo-172 BCG Vaccination

The bacilli Calmette-Guerin (BCG) Tokyo-172 strain was considered to exhibit good protective efficacy with a low rate of unfavorable side effects. However, we describe a rare case of BCG osteomyelitis developed in an immunocompetent host who was given with BCG Tokyo-172 vaccine on the left upper arm by multipuncture method. A 9-month-old girl presented with progressive inability to move her right elbow and had radiographic evidence of septic elbow combined with osteomyelitis of right distal humerus. A biopsy from the site revealed chronic caseating granulomatous inflammation, positive for BCG Tokyo-172 strain on the multiplex polymerase chain reaction. The child had to undergo second surgical debridements and oral antituberculosis chemotherapy. There were no sequelae after 2 yr of follow-up. This complication, although uncommon, should be considered in the appropriate clinical setting.

Infant Pertussis and Household Transmission in Korea

A recent resurgence of pertussis has raised public health concerns even in developed countries with high vaccination coverage. The aim of this study was to describe the clinical characteristics of infant pertussis, and to determine the relative importance of household transmission in Korea. The multicenter study was prospectively conducted from January 2009 to September 2011. We identified the demographic and clinical data from these patients and performed the diagnostic tests for pertussis in their household contacts. Twenty-one patients with confirmed pertussis were included in the analysis. All infections occurred in infants younger than 6 months of age (mean age, 2.5 months) who had not completed the primary DTaP vaccination except for one patient. Infants without immunization history had a significant higher lymphocytosis and longer duration of hospital stay compared to those with immunization. All were diagnosed with PCR (100%), however, culture tests showed the lowest sensitivity (42.9%). Presumed source of infection in household contacts was documented in 85.7%, mainly parents (52.6%). Pertussis had a major morbidity in young infants who were not fully immunized. Household members were responsible for pertussis transmission of infants in whom a source could be identified. The control of pertussis through booster vaccination with Tdap in family who is taking care of young infants is necessary in Korea.

Clinical Investigation of Bacteremia in Children with Hemato-Oncologic Diseases / 감염과화학요법

BACKGROUND: The purpose of this study was to determine the spectrum of locally prevalent pathogens and their susceptibility patterns responsible for bacteremia in pediatric hemato-oncologic patients for empiric antimicrobial therapy. MATERIALS AND METHODS: A one-year retrospective study of pediatric hematooncologic patients with bacteremia in Seoul St. Mary's Hospital, the Catholic University of Korea, from April 2009 to March 2010 was conducted using previous medical records. The findings were compared with our previous data obtained from 2004 to 2006. RESULTS: Sixty-five episodes of bacteremia were recorded in 41 patients. Of them, 55 (84.6%) occurred in neutropenic and 10 (15.4%) in non-neutropenic patients. Gram-positive organisms were more commonly isolated than Gram-negative organisms (56.9% vs. 41.5%) in the following order: viridans streptococci (23.1%), Klebsiella pneumoniae (21.6%), coagulase-negative staphylococci (12.3%), Staphylococcus aureus (7.7%), Enterococcus faecium (7.7%). Susceptibility rates of viridans streptococci to penicillin, cefotaxime and vancomycin were 33.3%, 60% and 100%, and those of Enterobacteriaceae to amikacin, ceftazidime, piperacillin/ tazobactam and meropenem were 94.7%, 73.7%, 78.9%, and 100%, respectively. Compared to our previous data, infection still contributed towards a major fraction of mortality and morbidity in the management of patients with cancer. No differences in mortality rate were observed between isolated organisms from bacteremia. CONCLUSIONS: Gram-positive organisms were more prevalent than Gram-negative organisms in our population. The monitoring of causative agents and antimicrobial resistance should be considered in therapeutic strategies of pediatric hemato-oncologic infection.

Clinical Features of BCG Lymphadenitis / 소아감염

PURPOSE:This study was performed to determine the clinical course of BCG lymphadenitis. METHODS:Between May 2005 and April 2009, the medical records of 33 patients with BCG lymphadenitis were retrospectively reviewed. If needed, needle aspiration was recommended without surgical resection or antituberculous medication. RESULTS:Of the 33 patients who were identified, 21 were males and 12 were females. Among the 33 patients, 32 were full-term babies. The mean age was 6 months (range, 2-35 months) and the most prevalent site of the lesion was the left axilla. BCG lymphadenitis was observed 1-34 months after BCG vaccination, mostly 1-6 months after vaccination. The size of the enlargement was generally 1-3 cm. The strains were identified as French (n=14), Danish (n=7), and Tokyo (n=12). BCG lymphadenitis regressed spontaneously in 19 patients. After 1-5 needle aspirations, 14 patients recovered completely. Complete regression of lymphadenitis was recorded over an average period of 4 months. CONCLUSION:Clinicians need to be aware of the clinical features of BCG lymphadenitis. For management of BCG lymphadenitis, regular follow-up with observation should be the mainstay. Needle aspiration is a safe and easy treatment for suppurative BCG lymphadenitis.

Complications of transcatheter closure of atrial septal defects using the amplatzer septal occluder / 소아과

PURPOSE: Transcatheter closure of atrial septal defects (ASD) is currently established therapy as an alternative to surgery. But rarely, complications are reported in some studies. We report early and intermediate term complications associated with transcatheter closure of atrial septal defects using the Amplatzer septal occluder (ASO). METHODS: From June 2003 to May 2006, 64 patients underwent transcatheter closure of secundum ASD or patent foramen ovale using the ASO. The ratio of male to female was 1:2.4, the median age was 17 years (range: 2.6-64 years) and their median weight was 47.5 kg (range: 2.6-64 kg). RESULTS: The median diameter of ASD measured with transthoracic or transesophageal echocardiography was 15 mm (range: 6-28 mm), the median balloon stretched diameter was 18 mm (range: 6.5-34 mm), and the median size of device was 19.5 mm (range: 6-36 mm), was little difference with balloon stretched diameter. There were 10 cases of complications: arrhythmia (2), device malformation (2), aorta to right atrial fistula (1), hemolytic anemia (1), mitral valve encroachment (1), malposition (1), residual shunt (1), and inferior vena cava perforation (1). CONCLUSION: Transcatheter closure of ASD using ASO is effective and safe therapy. However, significant complications such as aorta to atrial fistula, atrial erosion, or device embolization can happen, so an appropriate selection of patient and device in relevance to size and anatomy of ASD is important for successful closure.

Carotid artery intima media thickness in obese children: relation with cardiovascular risk factors / 소아과

PURPOSE: The of common carotid artery intima media thickness (IMT) is an acknowledged noninvasive marker for early atherosclerotic changes. We investigate whether common carotid IMT is different between obese and normal-weight children and also evaluate the relationships IMT with cardiovascular risk factors. METHODS: We collected the clinical data (age, sex, pubertal stage, body mass index) and measured blood pressure, glucose, insulin, lipid profiles and adiponectin in 49 obese children (mean age, 12 years) and 24 nonobese children as controls. The control group was composed of 24 nonobese children of the same age, sex and pubertal stage. We measured the carotid IMT of all subjects by B-mode ultrasound with a 7.5-MHz linear transducer and analyzed. RESULTS: Obese children demonstrated a significantly thicker intima media (mean, 0.34 mm, peak, 0.42 mm) compared to the control group (mean, 0.31 mm, peak, 0.38 mm, P<0.01). IMT was significantly correlated to the BMI (r=0.431, P<0.01), age (r=0.317, P<0.01), total cholesterol (r=0.377, P<0.01), triglyceride (r=0.253, P<0.05) and low-density lipoprotein cholesterol (r=0.289, P<0.05). Serum adiponectin was significantly lower in obese children than in controls (11.2 ng/mL vs. 14.7 ng/mL, P<0.05) and negatively related with IMT (r=-0.267, P<0.05). CONCLUSION: Obesity is associated with increased carotid artery IMT in children. Our results suggest vascular changes in obesity seem to occur already in childhood and vascular ultrasonography may helpful for screening cardiovascular complications in obese children.

Carotid artery intima media thickness in obese children: relation with cardiovascular risk factors / 소아과

PURPOSE: The of common carotid artery intima media thickness (IMT) is an acknowledged noninvasive marker for early atherosclerotic changes. We investigate whether common carotid IMT is different between obese and normal-weight children and also evaluate the relationships IMT with cardiovascular risk factors. METHODS: We collected the clinical data (age, sex, pubertal stage, body mass index) and measured blood pressure, glucose, insulin, lipid profiles and adiponectin in 49 obese children (mean age, 12 years) and 24 nonobese children as controls. The control group was composed of 24 nonobese children of the same age, sex and pubertal stage. We measured the carotid IMT of all subjects by B-mode ultrasound with a 7.5-MHz linear transducer and analyzed. RESULTS: Obese children demonstrated a significantly thicker intima media (mean, 0.34 mm, peak, 0.42 mm) compared to the control group (mean, 0.31 mm, peak, 0.38 mm, P<0.01). IMT was significantly correlated to the BMI (r=0.431, P<0.01), age (r=0.317, P<0.01), total cholesterol (r=0.377, P<0.01), triglyceride (r=0.253, P<0.05) and low-density lipoprotein cholesterol (r=0.289, P<0.05). Serum adiponectin was significantly lower in obese children than in controls (11.2 ng/mL vs. 14.7 ng/mL, P<0.05) and negatively related with IMT (r=-0.267, P<0.05). CONCLUSION: Obesity is associated with increased carotid artery IMT in children. Our results suggest vascular changes in obesity seem to occur already in childhood and vascular ultrasonography may helpful for screening cardiovascular complications in obese children.