Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

"All Patients Are Not Treated as Equal": Extending Medicine's Social Contract to Black/African American Communities.

PHENOMENON: The social contract is an implicit agreement that governs medicine's values, beliefs, and practices in ways that uphold the profession's commitment to society. While this agreement is assumed to include all patients, historical examples of medical experimentation and mistreatment suggest that medicine's social contract has not been extended to Black patients. We suggest that is because underlying medicine's contract with society is another contract; the racial contract, which favors white individuals and legitimizes the mistreatment of those who are nonwhite. When Black/African American physicians enter medicine, they enter into the social contract as an agreement with society, but must navigate the realities of the racial contract in ways that have yet to be acknowledged. This study examines how Black/African American physicians interpret and enact the social contract in light of the country's racial contract by investigating the ways in which Black/African American physicians discuss their interactions with Black patients. APPROACH: This qualitative study reexamines cross-sectional data previously collected in 2018-2019 examining the professional identity formation (PIF) experiences of Black/African American trainees and physicians in the Southern part of the U.S. The goal of the larger study was to explore participants' professional identity formation experiences as racialized individuals within a predominantly white profession. The current study examines these data in light of medicine's social contract with society and Mill's (1997) theory of the racial contract to understand how Black physicians interpret and enact the social contract. Participants included 10 Black/African American students, eight residents, and nine attending physicians. FINDINGS: The findings show that Black/African American physicians and trainees are aware of the country's racial contract, which has resulted in Black patients being historically excluded from what has been described in the social contract that governs all physicians. As such, they are actively working to extend the social contract so that it includes Black patients and their communities. Specifically, they engage in trust building with the Black community to make sure all patients are included. Building trust includes ensuring a consistent stream of new Black/African American trainees, and equipping Black trainees and patients with the skills needed to improve the healthcare within the Black/African American community. INSIGHTS: While it been has assumed that all patients are included in the social contract between medicine and society, historical examples of medical mistreatment and experimentation demonstrate this is inaccurate; Black/African American communities have not been included. In an effort to dismantle systemic racism in the U.S., medical education must teach about its racist past and divulge how some communities have been historically excluded, providing new ways to think about how to include everyone in medicine's social contract.

"When No One Sees You as Black": The Effect of Racial Violence on Black Trainees and Physicians.

PURPOSE: The United States has an implicit agreement known as the racial contract that exists between white and non-white communities. Recently, the racial contract has produced much tension, expressed in racial violence and police brutality. This study explores how this racial violence and police brutality have affected the practice and education of Black trainees and physicians who are members of the racial community being targeted. METHOD: This qualitative cross-sectional study interviewed 7 Black trainees and 12 physicians from 2 Southern medical schools in 2020. Interview data were collected using aspects of constructivist grounded theory, and then analyzed using the concept of racial trauma; a form of race-based stress minoritized individuals experience as a result of inferior treatment in society. Data were then organized by the causes participants cited for feeling unsafe, conditions they cited as producing these feelings, and the consequences these feelings had on their education and practice. RESULTS: The results show that even though participants were not direct victims of racial violence, because their social identity is linked to the Black community, they experienced these events vicariously. The increase in racial violence triggered unresolved personal and collective memories of intergenerational racial trauma, feelings of retraumatization after more than 400 years of mistreatment, and an awakening to the fact that the white community was unaware of their current and historical trauma. These events were felt in both their personal and professional lives. CONCLUSIONS: As more minoritized physicians enter medicine and medical education, the profession needs a deeper understanding of their unique experiences and sociohistorical contexts, and the effect that these contexts have on their education and practice. While all community members are responsible for this, leaders play an important role in creating psychologically safe places where issues of systemic racism can be addressed.

Evaluation of pediatric procedural sedation education in pediatric emergency medicine fellowships.

ABSTRACT: Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills.

"Changing the narrative": a study on professional identity formation among Black/African American physicians in the U.S.

Professional identity formation (PIF) is considered a key process in physician development. However, early PIF research may have inadvertently left out experiences from ethnically/racially minoritized physicians. As a result, the PIF literature may have forwarded dominant perspectives and assumptions about PIF that does not reflect those of minoritized physicians. This study used a cross-sectional study design, in which interview data was initially collected using constructivist grounded theory and then analyzed using critical lenses. Participants included 14 Black/African American students, 10 residents, and 17 attending physicians at two Southern medical schools in the U.S. Coding included the both/and conceptual framework developed out of Black feminist scholarship, and further analyzed using medicine's culture of Whiteness. These lenses identified assumptions made in the dominant PIF literature and how they compared to the experiences described by Black physicians. The results show that medical education's historical exclusion of minoritized physicians in medical education afforded a culture of Whiteness to proliferate, an influence that continues to frame the PIF research. Black physicians described their professional identity in terms of being in service to their racial/ethnic community, and the interconnectedness between personal/professional identities and context. Their professional identity was used to challenge larger social, historical, and cultural mistreatment of Black Americans, findings not described in the dominant PIF research. Black physicians' experiences as minoritized individuals within a culture of Whiteness reveals that the PIF literature is limited, and the current framings of PIF may be inadequate to study minoritized physicians.

What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine.

PURPOSE: Research on professional identity formation has largely ignored how race, ethnicity, and the larger sociohistorical context work to shape medical students' professional identity. Researchers investigated how physician-trainees considered underrepresented in medicine (URM) negotiate their professional identity within the larger sociohistorical context that casts them in a negative light. METHOD: In this qualitative study, 14 black/African American medical students were recruited from the Medical College of Georgia at Augusta University and Emory University College of Medicine between September 2018 and April 2019. Using constructive grounded theory and Swann's model of identity negotiation, the authors analyzed interview data for how students negotiate their racial and professional identities within medical education. RESULTS: The results indicated that URM students were aware of the negative stereotypes ascribed to black individuals and the potential for the medical community to view them negatively. In response, students employed identity cues and strategies to bring the community's perceptions in line with how they perceived themselves-black and a physician. Specifically, students actively worked to integrate their racial and professional identities by "giving back" to the African American community. Community-initiated mentoring from non-URM physicians helped to reify students' hope that they could have a racialized professional identity. CONCLUSIONS: Race, ethnicity, and the larger sociohistorical context is often overlooked in professional identity formation research, and this omission has resulted in an underappreciation of the challenges URM physicians' experience as they develop a professional identity. Within the context of this study, findings demonstrated that black/African American physicians negotiated the formation of professional identity within a challenging sociohistorical context, which should be given greater consideration in related research.