How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency.

OBJECTIVE: Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed. METHODS: We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development. RESULTS: We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives. CONCLUSIONS: Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism.

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.