Justifications for Discrepancies Between Competency Committee and Program Director Recommended Resident Supervisory Roles.

OBJECTIVE: To explore justifications for differences between summative entrustment decisions made about pediatric residents by individuals who are charged with the review of residents (clinical competency committee, or CCC, members) and those who ultimately make final summative decisions about resident performance (program directors, or PDs). METHODS: Individual CCC member and PD supervisory role categorizations were made in the 2015 to 2016 academic year at 14 pediatric residency programs, placing residents into 1 of 5 progressive supervisory roles. When PD recommendations differed from CCC members, a free-text justification was requested. Free-text responses were analyzed using manifest content analysis. RESULTS: In total, 801 supervisory role categorizations were made by both CCC members and PDs, with the same recommendations made in 685 cases. In the 116 instances of discrepancy, PDs assigned a lower level of supervisory responsibility (n = 73) more often than a greater one (n = 43). When moving residents to a greater supervisory role category, PDs had more justifications anchored in resident performance than experience. When moving residents to a lower supervisory role categorization, PDs conversely noted experience more than performance. CONCLUSIONS: PDs provide more justifications anchored in resident performance when moving residents to a greater supervisory role category compared with CCC members. However, when moving residents to a lower supervisory role categorization, they note experience more than performance. These patterns may or may not be entirely consistent with a competency-based approach and should be explored further.

Observations of Pediatric Disease Prevalence from Pacific Partnership 2015.

Pacific Partnership is an ongoing yearly humanitarian assistance mission to Pacific Rim countries. Although many case reports and surgical successes have been documented, few data have been published specifically about the primary care mission. This article analyzes outpatient pediatric data collected during Pacific Partnership 2015. Eleven different providers documented care delivered to children from birth through age 18 yr, inclusive. Personally de-identified data were entered into spreadsheets, sorted according to country visited, and analyzed with IBM SPSS software looking for disease frequency. One thousand eighty-seven pediatric patients were seen across Fiji, Papua New Guinea (PNG), and the Philippines (PI). Asthma was the first, second, and third most prevalent diagnosis in PNG, Fiji, and PI, with a relative proportion of the total patients seen at 5.4%, 7.2%, and 5%, respectively. In PI, 123 cases of upper respiratory infection were seen, more than four times the next most common diagnosis of normal exam. Thirty-six patients with scabies were seen in Fiji (number 1), with abdominal pain at number 3 (26 cases, 6.5%). Surprisingly, helminths were rarely seen, comprising the sixteenth and fourteenth most common diagnoses in Fiji and PI and only two cases in PNG. Future Pacific Partnership missions can plan medication stock, personnel assignment, equipment needs, and educational literature based on these data.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns.

BACKGROUND: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. METHODS: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. RESULTS: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. CONCLUSIONS: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Development of a Multi-Domain Assessment Tool for Quality Improvement Projects.

BACKGROUND: Improving the quality of health care and education has become a mandate at all levels within the medical profession. While several published quality improvement (QI) assessment tools exist, all have limitations in addressing the range of QI projects undertaken by learners in undergraduate medical education, graduate medical education, and continuing medical education. OBJECTIVE: We developed and validated a tool to assess QI projects with learner engagement across the educational continuum. METHODS: After reviewing existing tools, we interviewed local faculty who taught QI to understand how learners were engaged and what these faculty wanted in an ideal assessment tool. We then developed a list of competencies associated with QI, established items linked to these competencies, revised the items using an iterative process, and collected validity evidence for the tool. RESULTS: The resulting Multi-Domain Assessment of Quality Improvement Projects (MAQIP) rating tool contains 9 items, with criteria that may be completely fulfilled, partially fulfilled, or not fulfilled. Interrater reliability was 0.77. Untrained local faculty were able to use the tool with minimal guidance. CONCLUSIONS: The MAQIP is a 9-item, user-friendly tool that can be used to assess QI projects at various stages and to provide formative and summative feedback to learners at all levels.

Career-long learning: relationship between cognitive and metacognitive skills.

OBJECTIVES: Physicians need metacognitive skills including reflection and goal generation for effective lifelong learning (LLL). These skills are not readily assessed and may not correlate with cognitive skills. We examined early-career physicians' metacognition and relationships between metacognitive skills, cognitive skills, and orientation toward LLL. METHODS: Pediatric fellows at UCSF document career progress in annual Individual Development Plans (IDPs). To assess metacognitive skills, we scored narratives in IDPs with a Reflective Ability Rubric (RAR) and goal setting with a SMART Goal Rubric (SMART-GR: consists of global IDP score and four IDP domain subscores). To assess cognitive skills, we collected American Board of Pediatrics scores (ABP), and to measure orientation toward LLL, fellows completed the Jefferson Scale (JeffSPLL). We used Spearman's correlation to examine relationships between scores. RESULTS: About 57/66 (86%) fellows participated. Mean scores were: RAR 2.4 ± 1.3 (scale 0-6); SMART-GR global IDP 2.8 ± 1.0, (1-5); JeffSPLL 46.3 ± 3.9 (14-56); and ABP 559.4 ± 75.7. RAR scores correlated significantly with SMART-GR scores but metacognitive measures did not correlate with ABP scores. CONCLUSIONS: Our study suggests early-career physicians may have limited metacognitive skills; cognitive and metacognitive skills do not correlate; and orientation toward LLL does not predict metacognitive skills. Thus, we need improved methods to teach and assess metacognition.

Missing documentation of weight and height at preventive visits for children.

Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19,033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents.