Faculty Bibliography

Background: Traditional half-day per week continuity clinic experiences can lead to fragmented education in both the inpatient and outpatient arenas. Five pediatric residency programs were granted the ability from the ACGME in 2018 to create true X+Y scheduling models where residents see continuity clinic patients in "blocks" rather than half-day per week experiences.
Objective(s): Assess the impact X+Y scheduling has on pediatric resident perceptions of patient care and other educational experiences.
Method(s): Surveys were sent via REDCap to pediatric residents of the five participating X+Y pilot programs both prior to and 12 months after implementing an X+Y scheduling model. Survey questions measured resident perception of outpatient continuity, clinic schedule satisfaction, and the impact continuity clinic schedules had on inpatient and subspecialty rotation experiences using a 5-point Likert scale. Data were analyzed using z-tests for proportion differences for those answering Agree or Strongly Agree between baseline and post-implementation respondents.
Result(s): 126 out of 183 residents responded to the pre survey and 122 out of 259 residents responded to the post-implementation survey. Each outcome measure evaluated showed significant difference (p<0.01) between the pre and post-implementation surveys including the ability to have continuity with patients (27% pre-X+Y to 60% post-X+Y), quality of handoffs affected by clinic scheduling (69% pre to 10% post), and allowing adequate time for teaching on inpatient rotations (36% pre to 63% post) and in continuity clinic (35% pre to 72% post).
Conclusion(s): Residents perceive improved patient continuity and better quality of inpatient handoffs along with enhanced educational opportunities in X+Y scheduling compared to traditional half-day per week continuity clinic scheduling.
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Background: Traditional half-day per week continuity clinic experiences can lead to fragmented education in both the inpatient and outpatient arenas. Five pediatric residency programs were granted the ability from the ACGME in 2018 to create true X+Y scheduling models where residents see continuity clinic patients in blocks rather than half-day per week experiences.
Objective(s): Assess the impact X+Y scheduling has on pediatric faculty perceptions of patient care and other educational experiences.
Method(s): Surveys were sent via REDCap to faculty of the five participating X+Y pilot programs both prior to and 12 months after implementing an X+Y scheduling model. The surveys elicited the clinical focus of the faculty (general pediatrics, hospital medicine, or other subspecialties). Questions were then tailored to the area of clinical focus to determine the impact continuity clinic schedules had on general pediatrics, hospitalist, and subspecialty rotation experiences using a 5-point Likert scale. Data were analyzed using z-tests for proportion differences for those answering Agree or Strongly Agree between baseline and post-implementation respondents.
Result(s): 384 faculty members were sent the survey with 51% response pre-implementation and 32% response at 12 months. Each general pediatrics faculty outcome was improved in the X+Y model compared to traditional clinic schedules (p<0.05) including ability to have continuity with patients (64% pre to 93% post) and having adequate time for teaching (39% to 93%). Hospitalists noted decreased impacts on inpatient workflow with X+Y (79% to 29%). There was no statistical difference noted in teaching time by hospitalist or other subspecialty faculty.
Conclusion(s): General pediatric and hospitalist faculty perceive improved patient continuity and enhanced educational opportunities in X+Y scheduling compared to traditional half-day per week continuity clinics. Hospitalist and other subspecialty faculty note no significant impact on educational time after X+Y schedule implementation.
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Background: Clear family-centered communication is a foundation of practicing effective pediatric medicine. Formal communications training during residency is often limited and experience is mostly observational. Publications have shown that communication skills of trainees improve after a standardized curriculum, but family representatives were not included. In July 2019 we launched a communications curriculum for pediatric residents anchored in tenants of family-centered care that incorporates Family Faculty (FF), trained parents of patients cared for at our children's hospital.
Objective(s): To investigate how FF assessment of learners in an objective structured clinical exam (OSCE) differs from the gold standard of Standardized Patient (SP) assessment.
Method(s): We designed an OSCE in which the resident disclosed a medical error to a SP (playing a patients parent). The SP was trained in character portrayal and checklist completion. The 10-minute encounter was observed by an experienced clinician (EC) and FF through one-way glass, followed by a 20 minute debrief with the learner, SP, EC and FF. The SP, EC and FF all completed a 23-item behavioral anchored checklist that reflected 5 core competencies of family centered communication. Items were rated as not done, partly done or well-done, with well-done indicating mastery.
Result(s): 52 residents participated in the OSCE and 42 consented to study participation. The overall average % of learners considered to achieve mastery in each competency was lower as assessed by the FF vs SP: respect and value (50%vs.70%), information sharing (48%vs.67%), participation in care and decision making (40%vs.70%), follow-up (47%vs.60%), and team work (33%vs.52%).
Conclusion(s): Across all 5 competencies a lower % of learners reached skill mastery when assessed by FF as compared to SP. Involving FF in the evaluative and instructive components of the curriculum offers a more holistic approach and integrates true stakeholders in parent-physician communication. This initial data suggests that the resources needed to include FF in communications training is likely worthwhile.
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Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.

Background: Resident didactics often occur during noon conferences. In 2017, the New York University School of Medicine Pediatric Residency Program transitioned from daily noon conferences to a weekly 3-hour Academic Half Day (AHD). While internal medicine residency programs have shown an association between AHD and higher in-training exam (ITE) scores¹, the impact of AHD on pediatric resident ITE scores or satisfaction with preparation for the General Pediatric Board Exam is not well studied.
Objective(s): To investigate the impact of AHD on resident ITE scores and satisfaction with board preparation.
Method(s): We compared PGY2 raw ITE scores between the 2018 and 2019 graduating resident classes using a 2-sample t-test. We performed the same comparison for the PGY3 raw ITE scores. For the year between exams, the Class of 2018 received noon conferences, while the Class of 2019 received AHD. To assess resident satisfaction with board preparation, residents completed a survey prior to starting AHD and after 1 year. Satisfaction was reported on a Likert scale. Responses were categorized as "agree", "neutral", or "disagree" and analyzed with a chi-square test.
Result(s): There was no significant difference between the mean PGY2 ITE scores for the Class of 2018 (63.8 +/- 7.2) and 2019 (63.3 +/- 7.2) (p=0.8). The Class of 2019 had a significantly higher PGY3 ITE score (73.8 +/- 5.2) than the Class of 2018 (67.7 +/- 7.4) (p=0.01). When rating the statement "the current curriculum prepares me to take the boards", the percent of residents responding "agree" was 18% pre-AHD and 73% 1-year post-AHD. The association between initiation of AHD and satisfaction with exam preparation was statistically significant (X2=23.1, p<0.001).
Conclusion(s): The transition to an AHD had a positive impact on ITE scores and resident satisfaction with board preparation.
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Background: The transition from medical student to intern presents a major patient safety concern. Our institution implemented an immersive First Night OnCall (FNOC) simulation to support transitioning trainees and cultivate a culture of safety.
Objective(s): Engage pediatric interns in a pediatric focused FNOC simulation to ensure readiness to recognize and address common safety issues in practice.
Method(s): Interns were asked to recognize patient safety hazards in a simulated patient room and participate in case based safety discussions. Interns then participated in GOSCEs (Group Observed Standardized Clinical Encounters). GOSCEs tasked trainees to obtain informed consent, evaluate a decompensating patient, recognize a mislabeled culture bottle, and give an effective patient handoff. Faculty debriefed all activities. Learners completed pre and post program assessments and a program evaluation.
Result(s): Twenty incoming interns completed FNOC. Only 11% reported any prior formal training in patient safety. Interns recognized 46% of the environmental patient safety hazards. Out of the 5 GOSCE groups, 3 called a rapid response team, 3 noted the label error for the culture bottle, and 3 obtained complete informed consent. After FNOC, 92% of interns reported increased comfort (4 or 5 on 1-5 scale) in speaking to a supervisor, escalating a situation, and reporting a medical error. All interns agreed that the case based safety discussions and the patient safety room increased readiness for internship. Almost all of the interns (85%) agreed or strongly agreed that FNOC was an effective way to learn patient safety, a good approach to improve readiness, fun, and engaging.
Conclusion(s): Incoming interns are not consistently able to demonstrate common safety practices. Engaging, immersive, simulation based experiences like FNOC may reduce this variability, while simultaneously instilling aspirational institutional norms, promoting a culture of safety, and providing a framework for effective on-boarding strategies for new trainees.
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OBJECTIVE: To determine longitudinal measurements of resting energy expenditure (REE) by indirect calorimetry (IC) in healthy term infants during the first 2 months of life. STUDY DESIGN/METHODS:) with IC in a respiratory and metabolic steady state. RESULTS:production measurements were 9.3 ± 2.0 and 7.7 ± 1.2 mL/kg/min and 8.1 ± 2.2 and 6.4 ± 1.1 mL/kg/min at 1 and 2 months of age, respectively. CONCLUSION/CONCLUSIONS: This pilot study demonstrates longitudinal measurements of REE by IC in healthy term infants during the first 2 months of life. We also demonstrate that, overall, there is consistency in REE values in this population, with a likely decrease in individual longitudinal measurements over the first 2 months of life.

Background Maternal chorioamnionitis is a risk factor for sepsis but, often, these infants are asymptomatic at birth. Different markers for infections, such as the immature to total (I/T) white blood cell (WBC) ratio, are used to help determine which infants require lumbar punctures (LPs), in addition to blood cultures and antibiotics. The timing of when the complete blood count (CBC) is obtained may have some effect on the length of antibiotic treatment. Aims The purpose of this proof-of-concept study was to assess if obtaining a CBC at greater than four hours of life as compared to less than four hours of life has an impact on the incidence of LPs performed in asymptomatic, full-term infants undergoing evaluation for sepsis secondary to maternal chorioamnionitis. Methods We performed a retrospective study of full-term, asymptomatic infants admitted for sepsis evaluation secondary to maternal chorioamnionitis. Subjects were grouped based upon the timing of their initial CBC (early = < four hours of life or late = > four hours of life). The incidence of LPs, duration of antibiotic treatment, and length of hospitalization were compared between the groups. Results A total of 230 subjects were included in the study (early group = 124, late group = 106). Subjects in the late group underwent significantly fewer LPs than subjects in the early group, 5.7% vs. 22.6% (p<0.001). There was no difference in length of treatment or hospitalization. Conclusions Asymptomatic full-term infants undergoing evaluation for sepsis secondary to maternal chorioamnionitis are less likely to undergo an LP if their initial CBC is obtained at greater than four hours of life.

BACKGROUND:Infants with congenital diaphragmatic hernia (CDH) are at risk for growth failure because of inadequate caloric intake and high catabolic stress. There is limited data on resting energy expenditure (REE) in infants with CDH. AIMS/OBJECTIVE:To assess REE via indirect calorimetry (IC) in term infants with CDH who are no longer on respiratory support and nearing hospital discharge with advancing post-conceptional age and to assess measured-to-predicted REE using predictive equations. METHODS:A prospective cohort study of term infants with CDH who were no longer on respiratory support and nearing hospital discharge was conducted to assess REE via IC and caloric intake. Baseline characteristics and hospital course data were collected. Three day average caloric intake around time of IC testing was calculated. Change in REE with advancing post-conceptional age and advancing post-natal age was assessed. The average measured-to-predicted REE was calculated for the cohort using predictive equations [22]. RESULTS:Eighteen infants with CDH underwent IC. REE in infants with CDH increased with advancing postconceptional age (r2 = 0.3, p < 0.02). The mean REE for the entire group was 53.2 +/- 10.9 kcal/kg/day while the mean caloric intake was 101.2 +/- 17.4 kcal/kg/day. The mean measured-to-predicted ratio for the cohort was in the normal metabolic range (1.10 +/- 0.17) with 50% of infants considered hypermetabolic and 11% of infants considered hypo-metabolic. CONCLUSIONS:Infant survivors of CDH repair who are without respiratory support at time of neonatal hospital discharge have REE, as measured by indirect calorimetry, that increases with advancing post-conceptional age and that is within the normal metabolic range when compared to predictive equations. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. METHODS:Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). RESULTS:Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. CONCLUSIONS:NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.