Minimum accepted competency examination: test item analysis.

BACKGROUND: To ascertain if undergraduate medical students attain adequate knowledge to practice in paediatrics, we designed the minimum accepted competency (MAC) examination. This was a set of MCQ's designed to test the most basic, 'must know' knowledge as determined by non-faculty paediatric clinicians. Only two-thirds of undergraduate students passed this exam, despite 96% of the same cohort passing their official university paediatric examination. We aim to describe the psychometric properties of the MAC examination to explore why there was a difference in student performance between these two assessments which should, in theory, be testing the same subject area. We will also investigate if the MAC examination is a potentially reliable method of assessing undergraduate knowledge. METHODS: The MAC examination was sat by three groups of undergraduate medical students and paediatric trainee doctors. Test item analysis was performed using facility index, discrimination index and Cronbach's alpha. RESULTS: Test item difficulty on the MAC between each group was positively correlated. Correlation of item difficulty with the standard set for each item showed a statistically significant positive relationship. However, for 10 of the items, the mean score achieved by the candidates did not even reach two standard deviations below the standard set by the faculty. Medical students outperformed the trainee doctors on three items. 18 of 30 items achieved a discrimination index > 0.2. Cronbach's alpha ranged from 0.22-0.59. CONCLUSION: Despite faculty correctly judging that this would be a difficult paper for the candidates, there were a significant number of items on which students performed particularly badly. It is possible that the clinical emphasis in these non-faculty derived questions was juxtaposed with the factual recall often required for university examinations. The MAC examination highlights the difference in the level of knowledge expected of a junior doctor starting work in paediatrics between faculty and non-faculty clinicians and can identify gaps between the current curriculum and the 'hidden curriculum' required for real world clinical practice. The faculty comprises physicians in employment by the University whose role it is to design the paediatric curriculum and deliver teaching to undergraduate students. Non-faculty clinicians are paediatric physicians who work soley as clinicians with no affiliation to an educational institution. The concept of a MAC examination to test basic medical knowledge is feasible and the study presented is an encouraging first step towards this method of assessment.

Comparison of medical student performance in summative undergraduate paediatric examinations and a clinician-designed minimum accepted competency (MAC) assessment.

BACKGROUND: It is recognised that newly qualified doctors feel unprepared in many areas of their daily practice and that there is a gap between what students learn during medical school and their clinical responsibilities early in their postgraduate career. This study aimed to assess if undergraduate students and junior paediatric doctors met a Minimum Accepted Competency (MAC) of knowledge. METHODS: The knowledge of undergraduates and junior paediatric doctors was quantitatively assessed by their performance on a 30-item examination (the MAC examination). The items within this examination were designed by non-academic consultants to test 'must-know' knowledge for starting work in paediatrics. The performance of the students was compared with their official university examination results and with the performance of the junior doctors. RESULTS: For the undergraduate student cohort (n = 366) the mean examination score achieved was 45.9%. For the junior doctor cohort (n = 58) the mean examination score achieved was significantly higher, 64.2% (p < 0.01). 68% of undergraduate students attained the pass mark for the MAC examination whilst a significantly higher proportion, 97%, passed their official university examination (p < 0.01). A Spearman's rank co-efficient showed a moderate but statistically significant positive correlation between students results in their official university examinations and their score in the MAC examination. CONCLUSION: This work demonstrates a disparity between both student and junior doctor levels of knowledge with consultant expectations from an examination based on what front-line paediatricians determined as "must-know" standards. This study demonstrates the importance of involvement of end-users and future supervisors in undergraduate teaching.

Trends in road transport collision deaths in the Irish paediatric population: a retrospective review of mortality data, 1991-2015.

OBJECTIVE: To establish the incidence of road transport collision (RTC) fatalities in the Irish paediatric population, examining trends in fatality rates over a period of 25 years, during which several national road safety interventions were implemented. STUDY DESIGN: Retrospective review of death registration details of children 0-19 years in Ireland between January 1991 and December 2015. Trends in mortality rates were investigated using average annual per cent change and Poisson regression analysis. RESULTS: Proportionate RTC mortality, the majority of which occurred on public roads (94.1%, n=1432) increased with age; <0.3% (<1 year), 8.3% (1-14 years) and 18.4% (15-19 years) (2011-2015 average). Over time, rates declined significantly in all age groups; reductions of 79.0% (4.0 to 0.84/100 000, 1-14 years) and 68.4% (15.5 to 4.9/100 000, 15-19 years) resulted in 537 (95% CI 515 to 566) fewer child deaths (1-19 years) over the period 1996-2015. This reduction was evident for both road user types, the greatest decline (84.8%) among pedestrians 1-14 years (2.1 to 0.32/100 000) and the lowest (66.5%) among occupants 15-19 years, the majority of whom were male (12.4 to 4.2/100 000). The rate of decline was greatest during periods coinciding with introduction of targeted interventions. Risk of death in children 1-14 years was halved in the period after 2002 (incidence rate ratio (IRR) 0.52) while in children 15-19 years old, a significantly lower RTC fatality risk was evident after 2006 and 2010 (IRR 0.68 and IRR 0.50). CONCLUSION: Child and adolescent mortality from RTCs has declined dramatically in Ireland, in excess of reductions in overall paediatric mortality. However, rates remain higher than in other EU countries and further effort is required to reduce the number of deaths further, particularly among adolescent males.

Towards a more positive view of healthcare in Ireland.

Ireland has a population of just over one million children, the highest birth rate in the European Union, significant income inequalities and an increasing non-national population. Our under five mortality figures have shown a steady decline to 3.6 per 1000 and are amongst the best in the world. Examples of high-quality healthcare results include neonatal intensive care outcomes, paediatric cancer survival rates, surgical outcomes in congenital heart disease, improved survival in cystic fibrosis and renal transplantation results. Positivity alone is not enough and I propose a 10-point plan for future healthcare for children and young people. We should first and foremost aim for health not care and prevention plays a key role. Parents and families should play an active role in decisions around their children's health and should be aware of results of treatment. Care should be delivered as close to home as possible and we should strengthen both primary and community care and provide additional support to general practitioners to manage childhood illness closer to home. We need to plan for new morbidities such as type 1 diabetes, obesity, mental health issues and inflammatory bowel disease. General paediatrics is a key enabler of better healthcare for children. We should advocate for a future system focussed on quality, reducing geographical variation and supporting local care, thereby keeping children out of hospital as much as possible.

The association between infantile postural asymmetry and unsettled behaviour in babies.

Unsettled infant behaviour is a common problem of infancy without known aetiology or clearly effective management. Some manual therapists propose that musculoskeletal dysfunction contributes to unsettled infant behaviour, yet reported improvement following treatment is anecdotal. The infantile postural asymmetry measurement scale is a tool which measures infantile asymmetry, a form of musculoskeletal dysfunction. The first part of the study aimed to investigate its reliability and validity for measuring infantile postural asymmetry. This study also aimed to investigate whether there was an association between infantile postural asymmetry and unsettled infant behaviour and whether an association was mediated by, or confounded with, the demographic variables of age, sex, parity, birth weight and weight gain in 12- to 16-week-old infants. Fifty-eight infants were recruited and a quantitative cross-sectional observational design was used. An association between unsettled behaviour and infantile postural asymmetry was not found. A significant difference between high and low cervical rotation deficit groups for surgency was detected in female babies and needs further examination. CONCLUSION: Questions remain regarding the construct validity of the infantile postural asymmetry scale. No association between unsettled infant behaviour and infantile postural asymmetry was found in 12- to 16-week-old infants. The influence of sex on the interaction between infantile postural asymmetry and infant behaviour needs further examination. An association between unsettled infant behaviour and infantile postural asymmetry is still unproven. What is known: • Unsettled infant behaviour has a considerable impact on many family situations. • Identifying a definitive cause has been a source of much examination and research. Many different hypotheses have been suggested yet much is still unknown. What is new: • The association between unsettled infant behaviour and infantile postural asymmetry is still unproven. • The need to validate a reliable tool to measure infantile postural asymmetry, with particular focus on cervical spine rotation deficit, is indicated.

Child Health Care in Ireland.

The Irish health care system is based on a complex and costly mix of private, statutory, and voluntary provisions. The majority of health care expenditure comes from the state, with a significant proportion of acute hospital care funded from private insurance, but there are relatively high out-of-pocket costs for most service users. There is free access to acute hospital care, but not for primary care, for all children. About 40% of the population have free access to primary care. Universal preventive public health services, including vaccination and immunization, newborn blood spot screening, and universal neonatal hearing screening are free. Major health challenges include poverty, obesity, drug and alcohol use, and mental health. The health care system has been dominated for the last 5 years by the impact of the current recession, which has led to very sharp cuts in health care expenditure. It is unclear if the necessary substantial reform of the system will happen. Government policy calls for a move toward a patient-centered, primary care-led system, but without very substantial transfers of resources and investment in Information and Communication Technology, this is unlikely to occur.

Are boys and girls that different? An analysis of traumatic brain injury in children.

INTRODUCTION: The Phillips Report on traumatic brain injury (TBI) in Ireland found that injury was more frequent in men and that gender differences were present in childhood. This study determined when gender differences emerge and examined the effect of gender on the mechanism of injury, injury type and severity and outcome. METHODS: A national prospective, observational study was conducted over a 2-year period. All patients under 17 years of age referred to a neurosurgical service following TBI were included. Data on patient demographics, events surrounding injury, injury type and severity, patient management and outcome were collected from 'on-call' logbooks and neurosurgical admissions records. RESULTS: 342 patients were included. Falls were the leading cause of injury for both sexes. Boys' injuries tended to involve greater energy transfer and involved more risk-prone behaviour resulting in a higher rate of other (non-brain) injury and a higher mortality rate. Intentional injury occurred only in boys. While injury severity was similar for boys and girls, significant gender differences in injury type were present; extradural haematomas were significantly higher in boys (p=0.014) and subdural haematomas were significantly higher in girls (p=0.011). Mortality was 1.8% for girls and 4.3% for boys. CONCLUSIONS: Falls were responsible for most TBI, the home is the most common place of injury and non-operable TBI was common. These findings relate to all children. Significant gender differences exist from infancy. Boys sustained injuries associated with a greater energy transfer, were less likely to use protective devices and more likely to be injured deliberately. This results in a different pattern of injury, higher levels of associated injury and a higher mortality rate.

Paediatric primary care in Europe: variation between countries.

BACKGROUND: Although it is known that differences in paediatric primary care (PPC) are found throughout Europe, little information exists as to where, how and who delivers this care. The aim of this study was to collect information on the current existing situation of PPC in Europe. METHODS: A survey, in the form of a questionnaire, was distributed to the primary or secondary care delegates of 31 European countries asking for information concerning their primary paediatric care system, demographic data, professionals involved in primary care and details of their training. All of them were active paediatricians with a broad knowledge on how PPC is organised in their countries. RESULTS: Responses were received from 29 countries. Twelve countries (41%) have a family doctor/general practitioner (GP/FD) system, seven (24%) a paediatrician-based system and 10 (35%) a combined system. The total number of paediatricians in the 29 countries is 82 078 with 33 195 (40.4%) working in primary care. In only 15 countries (51.7%), paediatric age at the primary care level is defined as 0-18 years. Training in paediatrics is 5 years or more in 20 of the 29 countries. In nine countries, training is less than 5 years. The median training time of GPs/FDs in paediatrics is 4 months (IQR 3-6), with some countries having no formal paediatric training at all. The care of adolescents and involvement in school health programmes is undertaken by different health professionals (school doctors, GPs/FDs, nurses and paediatricians) depending on the country. CONCLUSIONS: Systems and organisations of PPC in Europe are heterogeneous. The same is true for paediatric training, school healthcare involvement and adolescent care. More research is needed to study specific healthcare indicators in order to evaluate the efficacy of different systems of PPC.