Alcohol Use by Youth.

Alcohol use continues to be a major concern from preadolescence through young adulthood in the United States. Results of recent neuroscience research have helped to elucidate neurobiological models of addiction, substantiated the deleterious effects of alcohol on adolescent brain development, and added additional evidence to support the call to prevent and reduce underage drinking. This technical report reviews the relevant literature and supports the accompanying policy statement in this issue of Pediatrics.

Educating and Training the Future Adolescent Health Workforce.

Unprecedented attention is now focused on adolescents with growing appreciation of their disease burden and of the opportunities of investing in adolescent health. New investments are required to build the technical capacity for policy, programming, research, and clinical care across the world, especially in resource-poor settings where most adolescents live. Strategies to educate and train the future workforce are needed. Competency-based education and training is the standard of education in preservice (undergraduate and postgraduate) health education and medical specialty training. Yet competency is difficult to quantify and standardize, as are the processes that underpin competency-based education and training. The primary objective of this review was to identify how quality education in adolescent health and medicine is determined. This information was used to inform the development of a conceptual framework for institutions teaching adolescent health, which can be used to assess the quality of teaching and learning and to monitor the implementation of these adolescent health competencies. Specific teaching modalities and assessment tools that have been used to teach adolescent health are described to exemplify how an educational program can be delivered and assessed. This framework is a step toward the development of a more adolescent-competent health workforce.

Developing Confidence in Uncertainty: Conflicting Roles of Trainees as They Become Educators in Veterinary and Human Medicine.

The important role of medical trainees (interns and residents) as teachers is increasingly recognized in veterinary and human medicine, but often is not supported through adult learning programs or other preparatory training methods. To develop appropriate teaching programs focused on effective clinical teaching, more understanding is needed about the support required for the trainee's teaching role. Following discussion among faculty members from education and veterinary and pediatric medicine, an experienced external observer and expert in higher education observed 28 incoming and outgoing veterinary and pediatric trainees in multiple clinical teaching settings over 10 weeks. Using an interpretative approach to analyze the data, we identified five dynamics that could serve as the foundation for a new program to support clinical teaching: (1) Novice-Expert, recognizing transitions between roles; (2) Collaboration-Individuality, recognizing the power of peer learning; (3) Confidence-Uncertainty, regarding the confidence to act; (4) Role-Interdisciplinarity, recognizing the ability to maintain a discrete role and yet synthesize knowledge and cope with complexity; and (5) Socialization-Identity, taking on different selves. Trainees in veterinary and human medicine appeared to have similar needs for support in teaching and would benefit from a variety of strategies: faculty should provide written guidelines and practical teaching tips; set clear expectations; establish sustained support strategies, including contact with an impartial educator; identify physical spaces in which to discuss teaching; provide continuous feedback; and facilitate peer observation across medical and veterinary clinical environments.

Long Term Outcomes of a Curriculum on Care for the Underserved.

ACKNOWLEDGEMENTS: This work was funded by HRSA grants D16HP00067 and D08PE50097. BACKGROUND: Evaluations of curricula to enhance ability to care for the underserved are often limited to short-term medical student outcomes. PURPOSE: This study evaluates retention of short-term improvements in outcomes from post-curriculum to graduation. METHODS: Third-year students on 2003-2004 pediatric clerkships were randomized to a curriculum on caring for the underserved in one of three formats: established "readings only", faculty-led, or web-based. Outcomes (knowledge, attitudes, self-efficacy and clinical skills) were assessed at three timepoints-pre- and post-curriculum and at graduation. Analyses, from 2009-2010, included Fisher's exact test to assess the relationship of curriculum group with response patterns, demographics, and outcomes at graduation. Multivariate regression was used to model the longitudinal relationship between outcomes and curriculum groups, adjusting for prior clerkship experiences, baseline scores, and clustering by student. RESULTS: Of 137 students, 135 (99%) completed the pre-curriculum survey, 128 (93%) completed the post-curriculum survey and 88 (64%) completed the graduation survey. Post-curriculum improvements in self-efficacy and clinical skills seen among students receiving the faculty-led or web-based curricula were retained at graduation. At graduation, web-based curriculum students' self-efficacy was significantly greater for "establishing achievable goals with underserved families" compared to established curriculum students. With regard to skills relevant to caring for the underserved, few graduates had facilitated a referral to Women, Infants and Children (33%) or followed up to ensure a patient accessed a needed resource (56%). CONCLUSIONS: Self-efficacy and skills gained through web-based and faculty-led curricula were retained at graduation. Data from items at graduation support targeted curricular improvement.

Protective factors in American Indian communities and adolescent violence.

With their distinct cultural heritage and rural boundaries, American Indian reservation communities offer a unique opportunity to explore protective factors that help buffer adolescents from potential risk behaviors such as violence. Prior published research on Indian communities has not explored three potential protective factors for violence-parental monitoring of adolescents and friends, adolescents' self-efficacy to avoid fighting, and adolescents' interest in learning more about their traditional culture. This paper explores the relationship between these factors and reduced risk of reported violence. In 1998, 630 American Indian students in grades 6-12 were surveyed in five Midwestern, rural Indian reservation schools. Path analysis was used to identify the direct and indirect association of the three potential protective factors with reduced violence behavior. There were significant gender differences both in perceived parental monitoring and in adolescents' self-efficacy. For female adolescents, parental monitoring had the strongest inverse relationship with female adolescents' involvement in violence. Female adolescents' self-efficacy and their interest in learning more about their culture were also inversely associated with violence and therefore potentially important protectors. Male adolescents who reported more interest in learning the tribe's culture had better self-efficacy to avoid violence. However, self-efficacy did not successfully predict their reported involvement in peer violence. These findings support exploring gender differences, parental monitoring, self-efficacy training as well as cultural elements in future violence intervention studies. Further investigation is needed to identify protective factors for risk behaviors among male adolescents and test the generalizability to non-reservation based adolescents.

The importance of social and collaborative learning for online continuing medical education (OCME): directions for future development and research.

BACKGROUND: There is an increasing use of online continuing medical education (OCME), but the potential use of social and collaborative learning to change professional performance and improve patient care has yet to be fully realised. METHODS: The integration of the main themes from the presentations and comments from participants at a symposium at AMEE 2011. RESULTS: Sociological perspectives on change in professional performance highlight the need for social and collaborative learning in OCME so that learners can share information (explicit knowledge) and opinion (tacit knowledge). The educational topic should be relevant to the complexity of professional practice and use iterative cycles of implementation and critical reflection in social networks so that proposed solutions can be tested in actual practice. The challenge of developing effective online discussions for collaborative learning is recognised. CONCLUSION: The provision of OCME requires a shift in both policy and practice to emphasise the importance of social and collaborative learning. Further research is recommended, especially to evaluate the implementation and impact of social and collaborative learning for OCME on patient care and the use of newer Web 2.0 approaches.

Substance use screening, brief intervention, and referral to treatment for pediatricians.

As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatrician's confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment-matching criteria and the risk level for substance abuse.

Perspective: viewing "strugglers" through a different lens: how a self-regulated learning perspective can help medical educators with assessment and remediation.

Medical educators are responsible for training current and future generations of physicians; this includes the early and accurate identification of "struggling" medical trainees, which has implications for future training, practice, and success.The authors propose a theory-based framework, Self-Regulated Learning-Microanalytic Assessment and Training (SRL-MAT), that is specifically designed to foster individual medical trainee self-regulatory beliefs and behaviors, and thus provide a distinct method to assist medical trainees who struggle. The SRL-MAT is grounded in social-cognitive theory and research and makes a variety of important assumptions about learning and the essential techniques needed to evaluate trainee functioning. Two critical assumptions are that (1) self-efficacy beliefs are a key personal process affecting trainee behavior, and (2) trainee beliefs and behaviors are dynamic and fluid in nature and thus will often vary across educational contexts, as well as for specific tasks within those contexts. To address these assumptions, the SRL-MAT uses an emergent assessment approach called self-regulated learning microanalysis, a procedure that involves asking a series of temporally sequenced questions about specific regulatory processes as trainees engage in an authentic task or activity. The framework, which is grounded in a foundation of established educational research, is adaptable to practically any task that has a clear beginning and end. The authors believe this framework could make important contributions to traditional medical training assessment frameworks that have been used to identify and remediate strugglers.

Care of the underserved: faculty development needs assessment.

INTRODUCTION: Because role models are crucial to training physicians to care for the underserved, we examined pediatric faculty's knowledge, attitudes, self-efficacy, skills, and precepting behaviors regarding care for this population. METHODS: Faculty knowledge, attitudes, self-efficacy, and skills/precepting behaviors were surveyed. RESULTS: Fifty-five (65%) of 85 faculty responded. The mean (standard deviation) knowledge score was 5.9 (1.3) of 8 possible. More than one-third of faculty did not recognize the eligibility criteria, services, and outcomes associated with common resources serving the underserved. Overall attitudes toward underserved families were positive, mean 3.3 (0.3), as was mean self-efficacy, 3.0 (0.7). Self-efficacy was lowest for accessing community resources for underserved families, 2.4 (0.7). Although most faculty performed the surveyed skills, fewer than 50% reported, precepting of these same skills with students. Precepting was lowest for accessing public and community resources. CONCLUSIONS: Low rates of student precepting as well as specific knowledge and self-efficacy deficits highlight potential targets for faculty development.

Alcohol use by youth and adolescents: a pediatric concern.

Alcohol use continues to be a major problem from preadolescence through young adulthood in the United States. Results of recent neuroscience research have substantiated the deleterious effects of alcohol on adolescent brain development and added even more evidence to support the call to prevent and reduce underaged drinking. Pediatricians should be knowledgeable about substance abuse to be able to recognize risk factors for alcohol and other substance abuse among youth, screen for use, provide appropriate brief interventions, and refer to treatment. The integration of alcohol use prevention programs in the community and our educational system from elementary school through college should be promoted by pediatricians and the health care community. Promotion of media responsibility to connect alcohol consumption with realistic consequences should be supported by pediatricians. Additional research into the prevention, screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents continues to be needed to improve evidence-based practices.

Physician practice change I: a critical review and description of an Integrated Systems Model.

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.

Physician practice change II: implications of the Integrated Systems Model (ISM) for the future of continuing medical education.

In a companion paper, the authors provide the development and description of the Integrated Systems Model (ISM). In this article, they describe 14 general implications of the ISM for continuing medical education (CME). They discuss how applying the ISM would change CME by describing (1) how CME and the larger health care environment would be restructured if they were based on the ISM and (2) how the ISM would impact CME under the current environment of health care in the United States. They close by describing how the ISM can be used as CME moves to address the long lag between discovery and practice and begins to decrease its dependence on pharmaceutical companies. The ISM helps not only explain why the current health care system in the United States (or anywhere) produces what it produces, but also predict what that system would produce if it changed. At present, the ISM is a conceptual model, but with more research into measures of its various elements, it could become a more quantitatively predictive model. In its present form, however, the ISM can serve Marinopoulos's call for a "sound conceptual model of what influences the effectiveness of CME" and address Grimshaw's concern that current research lacks "a theoretical base to support the choice and development of interventions as well as the interpretation of study results." The statistician George Box said, "All models are wrong, some models are useful." The authors believe that the ISM is useful and that maybe it will prove Box wrong.

Long-term outcomes of a primary care faculty development program at the University of Wisconsin.

BACKGROUND AND OBJECTIVES: To meet a need for primary care teachers, the Bureau of Health Professions funds faculty development programs for primary care preceptors. The purpose of this study was to determine how graduates of our faculty development program identified its long-term effect on professional outcomes. METHODS: Our program was a year-long series of five weekend workshops focusing on the preparation of preceptors to teach curricular areas relatively new to medical education--evidence-based medicine, teaching skills, technology tools, doctor-patient communication, quality improvement, and advocacy. Participants included physicians in community-based practices and university-based physicians. We surveyed the first 100 graduates of our program about professional and academic outcomes they attributed to program participation. Outcomes were categorized using the Kirkpatrick evaluation model; open-ended comments were analyzed thematically. RESULTS: Eighty responses were received (80% response rate). Ninety percent of respondents were teaching medical students and residents. Outcomes attributed to the program included improvement in teaching skills, improvement in clinical skills, intrapersonal growth and increased self-confidence, and increased interdisciplinary networking and mentoring. Ninety-one percent had recommended the program to others. CONCLUSIONS: Graduates identified positive outcomes and found the fellowship useful for developing the skills and self-confidence required of teachers. This training may be valuable for teachers in today's learning environment.

Clinical skills and self-efficacy after a curriculum on care for the underserved.

BACKGROUND: Despite calls for medical school curricula that address care for the underserved, published evaluations of such curricula are few and often do not assess clinical skills. This study assesses the changes in self-efficacy and clinical skills resulting from faculty-led or web-based curricula on care for the underserved. METHODS: Third-year students on 6-week 2003-2004 pediatric clerkships were block-randomized to a curriculum on caring for the underserved in one of three formats: established (readings only), faculty-led, or web-based. Primary outcomes were pre- and post-curriculum changes in self-efficacy and clinical skills. ANCOVA was used to test differences among curriculum groups, adjusting for prior experiences with the underserved. Analyses were performed in 2007. RESULTS: A total of 138 students participated, with 121 (88%) completing both pre- and post-tests. Compared to the established-curriculum students, both faculty-led and web-based students improved their self-efficacy in establishing achievable goals with underserved families, while web-based students improved their self-efficacy around knowledge of community resources. Significantly more new skills were performed by both faculty-led (mean [SD]=3.3[1.8]) and web-based curriculum students (2.9[1.5]), compared to established-curriculum students (1.5[1.4]). Compared to established-curriculum students, more faculty-led and web-based students also reported new skills in locating resources to meet the needs of underserved patients and in following up on referrals to ensure that families accessed needed care. CONCLUSIONS: Web-based and faculty-led curricula improve medical student self-efficacy and clinical skills. Results from specific self-efficacy and skill items facilitate targeted curricular improvement.

Defining characteristics of educational competencies.

CONTEXT: Doctor competencies have become an increasing focus of medical education at all levels. However, confusion exists regarding what constitutes a competency versus a goal, objective or outcome. OBJECTIVES: This article attempts to identify the characteristics that define a competency and proposes criteria that can be applied to distinguish between competencies, goals, objectives and outcomes. METHODS: We provide a brief overview of the history of competencies and compare competencies identified by international medical education organisations (CanMEDS 2005, Institute for International Medical Education, Dundee Outcome Model, Accreditation Council for Graduate Medical Education/American Board of Medical Specialties). Based upon this review and comparisons, as well as on definitions of competencies from the literature and theoretical and conceptual analyses of the underpinnings of competencies, the authors develop criteria that can serve to distinguish competencies from goals, objectives and outcomes. RESULTS: We propose 5 criteria which can be used to define a competency: it focuses on the performance of the end-product or goal-state of instruction; it reflects expectations that are external to the immediate instructional programme; it is expressible in terms of measurable behaviour; it uses a standard for judging competence that is not dependent upon the performance of other learners, and it informs learners, as well as other stakeholders, about what is expected of them. CONCLUSIONS: Competency-based medical education is likely to be here for the foreseeable future. Whether or not these 5 criteria, or some variation of them, become the ultimate defining criteria for what constitutes a competency, they represent an essential step towards clearing the confusion that reigns.

Abuse of proprietary (over-the-counter) drugs.

A predominantly overlooked type of substance abuse by adolescents and young adults in the United States and around the world is the abuse of medications and other products sold without a prescription, or over-the-counter (OTC), to the public. OTC substance abuse causes significant morbidity and mortality, and there are concerns that some types of OTC substance abuse are increasing. Regular office screening for inhalant abuse and other substance abuse and health risk behaviors must be part of standard pediatric care. This article discusses what is known about the extent and clinical impact of OTC substance abuse and reviews key points about recognition, detection, and management.

Caring for the underserved: blending service learning and a web-based curriculum.

BACKGROUND: Recognition of health disparities among underserved individuals, whose demographic, geographic, or economic characteristics impede access to health-related services, has led to calls for the development of medical school curricula that address care for the underserved, but reports of the development and evaluation of such curricula are limited. METHODS: Two formats of a curriculum addressing care for the underserved were developed and implemented during the 6-week pediatric clerkship for third-year medical students during the 2003-2004 academic year. One format was faculty-led; the other was web-based. Skills for providing care to underserved families were taught through didactic, experiential, and service-learning curriculum components. Novel core curriculum elements included a screening tool for recognizing underserved patients and an independent clinical project through which students linked underserved families with community health resources. Analyses from 2004-2005 compared pre- and post-curriculum knowledge and attitudes of web-based students (n = 29) to those receiving either the faculty-led (n = 36) or the established "readings-only" curriculum (n = 35). Qualitative data from service learning projects were analyzed to assess clinical skills. RESULTS: Compared to students in the established curriculum, both web-based and faculty-led students demonstrated improved knowledge (p < 0.001) and attitudes (p < 0.05) about caring for the underserved. Both web-based and faculty-led students were successful in recognizing and addressing underserved health issues in the clinical setting. CONCLUSIONS: Faculty-led and web-based curricula can equally improve student knowledge, attitudes, and skills about caring for the underserved.