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|Volume 53, Issue 3||July 2016|
After working hard to plan, lead and participate in the many successful APA activities at PAS in Baltimore, I hope everyone is enjoying summer and getting the chance for greatly deserved rest and relaxation with family and friends! It is a time for renewal as we start a new academic year and welcome our ever-younger looking new residents and fellows!
I am honored to work with you this year as President of the APA and to thank those who have served on the Board: Mark Schuster, Latha Chandran, Darcy Thompson and Cindy Osman and welcome our new Board Members: Sue Bostwick, Teri Turner, Allison Holmes and Tumaini Coker This summer we have a number of important APA initiatives. Under the leadership of Tumaini Coker we are working to expand the pipeline for diversity in academic pediatrics through the New Century Scholars program by collaborating with the American Pediatric Society and the Society for Pediatric Research. Finding interested mentors is one of the rate limiting elements for this program- please spread the word with colleagues or consider being a mentor!
The Annual Pediatric Hospital Medicine meeting is July 28-31st in Chicago. It is one of our largest APA meetings with over 800 attendees; co-sponsored with the American Academy of Pediatrics and Society for Hospital Medicine. Under the leadership of Dr. Barrett Fromme, APEX (Advancing Pediatric Education eXellence-an APA program co-sponsored with the AAP) will launch its third cohort at the PHM meeting.
The summer is an important time as we lay the groundwork for our November strategic planning meeting in Austin, Texas. We will also be sending out an important survey in the next few weeks to determine the future direction for the APA. We want to be sure that we are addressing your needs while determining how we can grow the APA by reaching out to others in academic pediatrics. We perceive that there are a number of pediatric specialists who could find a home in the APA for educational opportunities, mentorship and networking. To maximize value to current members and to attract new members, we would like to update our website to offer more opportunities to network virtually as well as deliver e-learning resources.
One initiative that I am exploring with the Education Committee, the APPD and COPS is to develop an online core curriculum for both academic and subspecialty fellows to address the core competencies around scholarship/research, teaching, advocacy and professionalism. If you already have e-learning resources are interested in collaborating to develop them please contact me at Mottolin@cnmc.org. I am always interested in hearing from current or prospective APA members- Have a wonderful summer!
Mary Ottolini, MD, MPH
We had a great PAS meeting in Baltimore this year and part of the credit for the success goes to the participation of our members in the workshop process. APA members were involved both in workshop review and as workshop leaders. 199 APA members participated in the workshop review process last fall. 89 workshops were presented at the meeting, many of which were led or co-led by APA members. The workshops were very well received and were rated highly on their evaluations.
The call for workshops for the 2017 meeting in San Francisco will go out in early July. Workshop proposals are due October 1st and notifications will go out in late October. Please consider sharing your skills and submitting a proposal. We are looking forward to another excellent program this year.
Thank you in advance to those who are submitting proposals and to those who have volunteered to review the proposals.
Your hard work and dedication to the PAS meeting and the process is appreciated and helps make the meeting a member-driven success.
Have a great rest of the summer and think workshops!
|APA New Members|
Irina Gennadyeena Trifonova
|APA Regional Meetings|
APA Region VI
September 30, 2016
St. Louis, MO
|2016 Pediatric Hospital Medicine|
2016 Pediatric Hospital Medicine
July 28 - 31, 2016
A special thanks to Latha Chandran, MD, MPH, the outgoing chair of the Education Committee, for her superb leadership over this past three years! She is a great teacher, mentor, educational scholar, and leader.
The highlight of this year's Education Committee meeting, chaired by Dr. Chandran, was a session on "Innovations in Medical Education" which was facilitated by Dr. Larry Greenberg. The committee heard about 5 unique programs happening across the country.
Teaching Tip: Stop, Start, and Continue Structured Feedback Method Increase the Quality of Feedback
One of the first feedback tools I learned to use in the Academic Pediatric Association was the "Plus Delta" structured feedback tool. The tool is a blank sheet of paper with a vertical line dividing the sheet into two halves. On the top of the left hand side a plus symbol (+) and on the right hand side, the Greek uppercase letter for delta (Δ), On the left hand side we were to list teaching behaviors/actions which were helpful to our learning, on the right, suggestions for change to improve learning. Hoon et al. studied the quality of feedback using either a free text box for feedback or a structured feedback tool like the "Plus Delta" which asked students to identify aspects of instruction that the teacher should "stop doing, things they'd like the teacher to consider doing, and those practices they'd recommend that the teacher continue doing." The structured tool "Stop, Start, and Continue" resulted in higher quality feedback and clarified the impact of specific aspects of instruction. More importantly it makes students responsible for suggesting alternatives. The next time you would like to receive specific comments and suggestions to help improve your teaching, use a simple structured format like "Plus Delta" or "Stop, Start, and Continue." It doesn't mean doing everything the students recommend but it can provide you with alternatives that you might not have considered. Plus it teaches students some of the principles of constructive feedback. A win-win for both teachers and learners.
Hoon A, Oliver E, Szpakowska K, Newton P. Use of the 'Stop, Start, Continue' method is associated with the production of constructive qualitative feedback by students in higher education. Assessment & Evaluation in Higher Education. 2015 Jul 4;40(5):755-67.
Apps for Teaching: BaiBoard (http://www.baiboard.com/)
Baiboard is a free cloud based collaboration app that enables users to create and collaborate on educational content, through the use of collaborative whiteboard, voice conferencing, document annotation etc. Check out the review at http://appedreview.com/app/baiboard-collaborative-whiteboard/
Article worth reading (and sharing)
In addition to the great articles published in Academic Pediatrics, consider reading the article below. Calls for abstracts for the Pediatric Academic Society, the Association for Pediatric Program Directors Spring meeting and the Council on Medical Student Education in Pediatrics annual meeting will be forthcoming in the next few months and this will help you with your submission.
Cook DA, Bordage G. Twelve tips on writing abstracts and titles: How to get people to use and cite your work. Medical teacher. 2016 May 30:1-5.
|Academic General Pediatric Fellowship Accreditation Committee (AGPAC)|
This past year, the University of Minnesota (UMN) Interdisciplinary Research Training in Child & Adolescent Primary Care (IRT-CAPC) fellowship training program became the 16th Academic General Pediatric fellowship training program accredited by the AGPAC. Congratulations to Dr. Iris Borowsky, MD, PhD for her outstanding leadership of this program!
The AGPAC hosted a pre-PAS conference on April 28th in Baltimore entitled: Negotiating the Academic Waters: Building a successful career from fellowship to faculty. Over 50 fellows and fellowship program leaders attended this one day event. The conference provided opportunities to network, to develop professionally and for fellows to share scholarly interests in research, education, quality improvement or advocacy. Twenty-five fellowship trainees presented their works-in-progress at the meeting and received both peer and faculty feedback. Trainees and faculty participated in two workshops: Be Your Own Best Advocate: Promoting and Negotiating One’s Career in Academic Medicine and How to Hit the Ground Running as New Faculty. There was also a panel discussion with general pediatric fellowship program directors and former fellows which was lively and informative. The committee would like to thank all the individuals below who presented or served on the planning committee as well as all the fellowship program leaders. The conference was supported and underwritten by the Academic General Pediatric Fellowship Accreditation Committee of the Academic Pediatric Association.
Louis Bell, MD
Daniel Coury, MD
Benard Dreyer, MD
Marybeth Jones, MD
Paul Darden, MD
Thomas DeWitt, MD
Robert Hilliard, FRCPC, MD, EdD
Jimmy Beck, MD, MEd
Benard Dreyer, MD
Julieana Nichols, MD, MPH
Mary Ottolini, MD, MPH
Peter Szilagyi, MD, MPH
Lauren Solan, MD, MEd
Teri Turner, MD, MPH, Med
Neha Shah, MD, MPH
Melissa Klein, MD, MEd
|Advancing Pediatric Educator Excellence (APEX) - an APA co-sponsored program|
The following 22 individuals will be graduating this month from the APEX program. Congratulations from the APA!
|Steve Bachta, MD, Floating Hospital for Children at Tufts Medical
Vanessa Baptiste, MD, Cohen Children's Medical Center of New York
LaToya Barber, MD, USC Keck School of Medicine
Avni Bhalakia. MD, Children's Hospital of Montefiore
Elizabeth Davis, MD, Baylor College of Medicine
Stephanie DeLeon, MD, OUHSC Department of Pediatrics
Maya Eady, MD, U. of Tennessee Health Services Center
Hetal Gadhia, DO, Baylor College of Medicine
Jorje Ganem, MD, Dell Children's Medical Center
Luis Garcia-Chacon, MD, PhD, U. of Miami Department of Pediatrics
Pratichi Goenka, MD, Cohen Children's Medical Center of New York
MacKenzi Hillard, MD,MS, Weill Cornell Medical College
Akshata Hopkins, MD, Johns Hopkins Medicine
Nardin Tadros Ibrahim, MD, St. Barnabas Medical Center
Christine Marrese,MD, Children's Hospital of Montefiore
Natalie McKnight, MD, Inova Children's Hospital
Mohammed Najjar, MD, Children's Hospital of Michigan
Kamakshya Patra, MD, WVU Health Science Center
Christopher Russo, MD, Centra Lynchburg General Hospital
Kathryn Schneider, MD, U. of Mississippi Medical Center
Margaret Trost, MD, USC Keck School of Medicine
Arnaldo Zayas- Santiago, MD, Cleveland Clinic
Dear CORNET Members,
We wanted to share with you what is new within CORNET.
In Progress: National Immunization Partnership with the APA (NIPA)
This large-scale, quality improvement project coaches clinical sites through practice changes in order to increase adolescent HPV vaccination rates and limit missed opportunities for HPV vaccination at every clinic visit.
Faculty who meet minimum participation requirements will receive MOC 4 credit. Moreover we are excited that we will be able to offer banked MOC credit for residents as well.
We are finalizing data collection and will begin the data analysis stage with our sites participating in Wave 1. We are entering the third month of intervention with our sites participating in Wave 2. We expect to start a third wave in early 2017. If your site is interested in joining, please contact Holly Tyrrell at Hollyce@academicpeds.org for details.
In Progress: Preventive Services Improvement Project – State Spread (PreSIPS2)
A quality improvement initiative based on Bright Futures to improve the preventive health outcomes of young children is underway. Four Continuity Clinics from CORNET are participating in this collaborative project with AAP State Chapters. Measurement-based preventive services, implemented by faculty and residents in continuity clinics, are the key to the "future" of Bright Futures as well as incorporation into community practices as our residents transition into their professional careers.
Completed Project: The National Partnership for Adolescent Immunization (NPAI) project has been completed. Data from this study were presented at PAS in April. We anticipate 3 manuscripts from this project and they are in preparation.
PAS 2016 Recap
Thank you to everyone who attended the CORNET Members Meeting at PAS in April. We are excited for new projects and partnerships moving forward! We are especially excited about our new collaboration with Family Voices, a national parent advocacy group. Our new Network Director, Iman Sharif, and Network Coordinator, Holly Tyrrell, are working hard to fill the shoes as Janet and Nui transition from their prior roles.
Region Research Chair Recruitment
We are seeking APA CORNET members from Region I and Region X to serve as members of the CORNET Executive Committee in the role as the Regional Research Chairs. As a member of this Committee, you will benefit by acquiring new skills from other members, enhancing networking while making new friends and professional contacts, and developing opportunities for collaborative research. Moreover, this is a great way to add "national contributions" to your CV.
The CORNET Executive Committee will review and consider the materials submitted from all interested applicants for this position.
The Role of a CORNET Regional Research Chair is to:
To apply, please submit your name, CV, and a brief summary describing your interest in serving on the CORNET Executive Committee as a Regional Research Chair to email@example.com.
Do you know your Regional Research Chair?
Here is the current list of CORNET chairs by APA region. Please reach out to your local contact for any questions or research ideas. They would be happy to provide you with guidance and suggestions.
Region I: To be filled
Region II: Allison Gorman, firstname.lastname@example.org
Region III: Lynn Garfunkel, email@example.com
Region IV: Mike Steiner, firstname.lastname@example.org
Region V: Heather Burrows, email@example.com
Region VI: Sue Heaney, Heaney@slu.edu
Region VII: Teresa Duryea, firstname.lastname@example.org
Region VIII: Sharon Dabrow, email@example.com
Region IX: Wendy Hobson-Rohrer, firstname.lastname@example.org
Region X: To be filled
|Educational Scholars Program|
Educational Scholars Program Celebrates!
The Educational Scholars Program celebrated its 10 year anniversary in Baltimore with a great party, keynote address by the APA President, and inspiring presentations by three of our graduates. It was a welcome opportunity to reflect on the past and take pride in the many accomplishments of the program, as well as think about the future of the ESP. Many thanks to Committee Co-Chairs Melissa Klein and Barry Solomon and the enthusiastic group of ESP graduates who planned this event! And thanks to all who attended!
The ESP has a lot of successes to celebrate:
We were delighted to graduate 15 scholars, all of whom received a Certificate of Excellence in Educational Scholarship at the 10th Anniversary Celebration. Graduates' projects included a wide variety of topics such as professionalism, teaching family centered rounds, EBM, child advocacy, and inter-professional teamwork.
We also welcomed a new cohort to the program in Baltimore. Cohort 8 includes 26 scholars from all over the US. Hans Kersten is the leader of this cohort and in this role has joined the ESP Executive Committee.
Hello Region 4 members!
Another successful Region 4 breakfast meeting at PAS 2016 is in the books! It was a great time to catch up with friends, make new connections, and get the latest updates and happenings from our region's institutions. It was also time to say "Thank You" to Carl Seashore who tirelessly led and served our region for the past three years. A plaque of gratitude was presented to Carl at the breakfast. Dr. Melissa Long was elected to replace Carl as the incoming region co-chair.
Melissa Long, MD is a pediatrician at the Children's Health Center in Washington, DC. She received her medical degree from the University of California, San Francisco and completed her pediatric residency at Johns Hopkins. She has been on faculty at the Goldberg Center for Community Pediatric Health at Children's National Health System since 2012 and is an Assistant Professor of Pediatrics at George Washington University School of Medicine and Health Sciences. In addition to teaching medical students and residents in the outpatient setting, her academic work focuses on mental health integration in pediatric primary care. She was a project lead on a recent quality improvement project designed to implement routine mental health screening at the Children's Health Center. She has also been active in Region IV of the Academic Pediatric Association, serving on the annual meeting planning committee for the past three years.
Dr. Long will join Drs. Megan Tschudy and Clifton Lee to carry out the Region IV business and represent the region in the Academic Pediatric Association. Congratulation and welcome, Melissa!
Finally, please SAVE THE DATE! The Region 4 conference will be held February 11-12, 2017 in beautiful Charlottesville, VA (note: this is a change from what was announced at PAS). Look for more details to come in the early fall.
Have a great summer, stay safe, and don't forget the sun screen!
Megan Tschudy, Cliff Lee, and Melissa Long
Save the Date for 2016 Region VI Fall meeting:
Friday, September 30, 2016 at Saint Louis University and SSM Health Cardinal Glennon Children's Hospital in St. Louis, MO
Dr. Mary Ottolini, APA President and Vice Chair of Medical Education at Children's National Medical Center, will be our featured speaker ("Failure: How to Turn Challenges into Stepping Stones for Success") during a full-day meeting that will be designed with something for everyone. Drs. Angela Sharkey (Saint Louis University) and Lisa Moscoso (Washington University) will also lead a workshop on "Mentorship, Sponsorship and Academic Advancement". Dr. Stuart Slavin (Saint Louis University) will run a session "Stress and Burnout in Academic Pediatric Practice: Challenges and Opportunities" and Dr. Rebecca Benson (University of Iowa) will lead on "Lifelong Learning in End of Life Situations".
As always, we will have a leadership panel, poster session, lunch and an awesome networking event the night before. Please put this date on your calendar and plan to attend along with others from all over the region.
Matthew Broom, MD
Saint Louis University School of Medicine
1465 South Grand Blvd
St. Louis, MO 63104
Phone: (314) 268-4150
Grace Brouillette, DO, MBA
3901 Rainbow Boulevard
Kansas City, KS 66160
Phone: (913) 588-6329
Jessica Bettenhausen, MD
Children's Mercy Hospital
2401 Gillham Road
Kansas City, MO 64108
Phone: (816) 802-1493
|Special Interest Groups|
Happy Summer Everyone,
At the conclusion of PAS 2017, Drs. Marny Dunlap, Nancy Kelly, and Marjorie Rosenthal will step down after completing their terms as Advocacy Training SIG Co-chairs. Dr. Sara Bode will continue on for another year and we'll also welcome 2 new co-chairs. Nominations were solicited and elections for the 2 new co-chairs will be held June 27-July 22, 2016.
Next year at PAS, the Advocacy Training SIG will partner with Environmental Health Training SIG for a joint session. We'll post more details as we begin to plan out this exciting session!
Have a wonderful summer!
Your Advocacy Training Co-Chairs,
|Child Abuse and Neglect|
SIG Annual Report
Kristine Campbell, University of Utah
Cynthia DeLago, Einstein Medical Center
To provide a forum for child health professionals that supports innovation in prevention, advocacy, policy, research, and education related to the care of children at risk for or impacted by child abuse or neglect.
Current SIG goals:
To provide an annual workshop that inspires participants to walk away with new perspectives on a challenging issue in child abuse pediatrics today.
The Child Abuse and Neglect Special Interest Group convened in the final hours of the Pediatric Academic Societies Meeting in Baltimore, Maryland. Despite finding ourselves in the waning hours of the conference, we had a great turnout, with at least 38 participants hailing from as close by as the University of Maryland and from as far away as New Zealand, Taiwan, and Denmark.
This year's workshop was titled "Child Abuse Medicine: Past, Present, and Future." We were honored to have 3 fantastic presenters address different perspectives on evolving and emerging research in child abuse pediatrics.
We ended with a series of questions from the audience.
Other groups that work in your area of interest:
While we are not actively working with other SIGs, we see ample opportunity for collaborating around the annual PAS workshop if other groups are interested.
Thanks to all who participated in our PAS workshop. If you have any suggestions for topics next year, please contact Kris Campbell (email@example.com) or Cindy DeLago (DeLagoC@einstein.edu). Also, we will be looking for energetic new chairs to join us in the next year—please let us know if you are interested.
We had a very successful e-Learning SIG meeting at the PAS 2016 in Baltimore. We had over 50 attendees with a follow-up meeting at the PAS to discuss the future direction of the SIG. Following some welcoming remarks, attendees were presented with four dynamic presentations.
Kadriye Lewis Ed.D presented how can we use behavioral data from academic technologies and other conventional data sources to improve learner achievement. Dr. Lewis also discussed how can learning analytics fit in medical education in the concept of instructional design, and assessment of learning.
Traci Wolbrink MD presented how is serious gaming utilized in medical education as well as discussed what are the key features that make serious gaming especially appealing to adult learners.
Jacqueline Walker MD demonstrated how ePortfolios are used to support professional development in medical practice.
Jeffrey Sestokas M. Ed discussed how does one use various open source e-Learning plugins for incentivizing, gamifying, and informing learners within an open source learning management system.
Changes in e-Learning SIG in Medical Education
It has been over nine years since Dr. Kadriye O. Lewis has started the E-Learning in Medical Education Special Interest Group (SIG) for the members of Academic Pediatrics Association. She has remained an important advisor for this group. We are excited to nominate as the third Co-Chair of the SIG Jeff Sestokas M.Ed from Children's National. Jeff has vast experience in instructional systems design and technology and has been well versed in developing simulation exercise training applications.
We are excited to keep the momentum going beyond the meeting and help participants actively engage in the e-learning network of medical educators. In the coming weeks, we plan to introduce the following initiatives:
Dear Ethics SIG members,
We had a well-attended and very well received meeting in Baltimore. We had three speakers from three different institutions tackling the ethical issues involving decision making for technology dependent children. There was spirited debate on how to balance autonomy of parents, best interest of the children and also the society which highlight that ethical issues cannot be solved with a single approach.
As in previous years, we held our annual ethics SIG essay contest. Fourteen essays were submitted from various different programs within the United States and Canada. Our judges of these essays were interprofessional, interdisciplinary and international. First and second place winners were invited and first prize winner's essay was read by one of her colleagues. You can find the winning essays at the end of this letter.
As we have already started to plan for next year we would love to hear any ideas/topics that you would like to be presented. In this way we can plan our next session according to your needs/wishes.
We would also like to announce our sixth annual ethics SIG ethics essay contest. Please find the official announcement at the end of this letter.
We will keep in touch via our newsletter and we will continue to be a platform sharing our views and concerns about the impacts of ethics in our clinical work, research and teaching.
Ethics SIG Co-Chairs
Zeynep Salih, M.D., MA
Adrian Lavery, M.D., MPH
We had an informative and very interactive SIG this year with at least 35 people in attendance.
Sarah Mennito shared her expertise and experience at MUSC in developing evidence based order sets. She highlighted the importance of a team-based approach, including librarians, quality officers, physicians and other health care providers in defining PICO questions, obtaining and evaluating the evidence, and providing links within the EMR to support decision making. Residents are also crucial to the process in identifying optimal work-flow and potential issues.
Following Dr. Mennito's presentation we learned about EBM curricula at three different institutions. Chrystal Wittcopp, Julie Sanville, Anne Hanley and Kevin O'Callaghan described the multi-faceted and longitudinal approach of Baystate Children's, including EBM morning reports, educational prescriptions and journal article reviews on subspecialty rotations. Ana Creo presented Mayo's curriculum, which includes a didactic board-relevant curriculum along with point-of care practice utilizing iPADs in the clinical setting. Kathryn Spectorsky described the curriculum at Children's Mercy Hospital, with a focus on clinical practice guidelines, quality improvement, and encouraging participation of subspecialty faculty.
Following these three presentations, the group had a lively question/answer session and discussion regarding curricular design and strategies.
In a brief business meeting, Adam Schickendanz highlighted some activities of the Health Care Value SIG (in its inaugural year), highlighting resources through the ACP, including Pediatric-specific on-line modules, accessed at https://www.acponline.org/clinical-information/high-value-care/resources-for-clinicians/high-value-care-pediatric-cases. Rachel Boykan and Bob Jacobson updated the group on the progress of the Librarian study initiated at last year's SIG; data are currently being analyzed. Bob Jacobson encouraged the group to participate in resubmitting the HPV grant application - which the SIG came in 3rd place for last year. Other ideas for collaboration were solicited and participants were reminded to complete evaluations on line and to provide feedback and ideas for next year's presentations.
Finally, Ricardo Quinonez spoke about dogmas in pediatrics and the evidence (or lack thereof) behind them. He highlighted three examples - breast-feeding, flu vaccines and consideration of UTI as serious bacterial infection - which provided the group with much food for thought and continued discussion.
We hope everyone enjoyed PAS 2016 as much as we did! The Health Literacy SIG has enjoyed a productive past year culminating in a stimulating interactive session.
Over the past year, members of our SIG have been working on creating education modules focused on health literacy training as well as collaborating on a grant we received from the APA.
SIG members have been working on creating curriculum based on the content of each of the two workshops we presented at PAS 2015, one focused on promoting the adoption of health literacy concepts in practice and research, "Health Literacy from ‘Bench’ to Bedside: Verbal, Written, and Technological Tools for Clear Communication in Clinical Practice and Research" and the other focusing on health literacy education across the continuum of medical learners, "Doctors are From Mars, Patients are From Venus."
Another group of SIG members have nearly completed work on a grant from the APA, funded by the CDC, to address low HPV immunization rates in teens using a health literacy perspective. We completed an environmental scan of current existing patient education handouts, assessing their health literacy attributes (e.g. readability, suitability) and their content. We also held focus groups with physicians at 3 of the collaborating sites to explore their perceptions of barriers to HPV vaccination and potential strategies to address these barriers. Finally, we held structured interviews with 25 parents across each of the 3 sites to receive their input on the adequacy, appropriateness and understandability of 4 top rated handouts identified as part of the environmental scan.
Our SIG session at PAS this year reflected our SIG’s goals of promoting research, education and policies to advance the integration of health literacy into health care delivery systems. The talk, "Becoming a Health Literate Organization: A Journey with Urgency", presented by Laura Noonan, MD, of the Carolinas Health System in North Carolina, demonstrated to all of us, the great work that system has been doing and the promising approach of using quality improvement science to incorporate health literacy into an institution as a way to improve patient experiences and outcomes.
In the second half of the SIG session, we broke into 3 groups - education, research and policy - and focused on developing our pediatric priorities for the future of health literacy research, education and advocacy. These priorities were shared with the National Institute of Engineering, Science and Medicine (formerly the IOM) who held a strategic meeting in May to set their priorities for the coming 5 years. The education group also worked on the curriculum we are preparing based on the health literacy education workshop.
As we look towards the coming year, the co-chairs, Shonna Yin and Barbara Bayldon, will be holding an election this summer to replace Lee Sanders, one of the original two co-chairs, who is stepping down. We hope to submit our two modules to the MedEdPORTAL, a peer reviewed site, by the fall of this year, to continue to foster collaborative research and mentorship of younger investigators, and possibly extend our current APA/CDC grant for a second phase to address teen barriers to receipt of the HPV vaccine.
NEWBORN NURSERY SIG-MEETING SUMMARY
MAY 2nd 2016
Esther K. Chung and Mary Ann LoFrumento - Co-Chairs
We had a robust turnout for our NB Nursery SIG with participants from all over the US and beyond, from as far away as South America and New Zealand.
Objectives: To learn the latest evidence-based information to help us give newborns and their parents the healthiest start possible and to teach medical students and residents the fine art and science of newborn care.
Our keynote speaker was Dr. Richard A. Polin, the William T. Speck Professor of Pediatrics at Columbia University, College of Physicians and Surgeons and the Director of the Division of Neonatology at Morgan Stanley Children's Hospital of New York-Presbyterian. His talk, entitled "Neonatal Hypoglycemia: Beyond Quadraginta Septem Phobia (the fear of 47)", brilliantly took us through the history of neonatal hypoglycemia management as well as current studies, and suggested that a single glucose value cannot define hypoglycemia. He touched on the current guidelines both from Endocrinology and from Neonatology and how they at times contradict one another. He concluded that no guideline is perfect and there is little consensus on the significance of transient and asymptomatic hypoglycemia. (Slides available in the wiki)
Dr. Alison Holmes and Dr. Bonny Whalen presented the QI topic, "Improved family centered care at lower cost: Rooming-in to treat neonatal abstinence syndrome (NAS)," an alternative treatment for NAS being undertaken at Children's Hospital of Dartmouth that keeps baby and mother together. With this approach they have had a dramatic decrease in infants requiring pharmacological intervention in the NICU, and a decrease in length of stay and cost for the hospital. (Slides available in the wiki)
Eight posters had been selected for display, and there was much excitement and discussion around all of them. One of our poster presenters, Dr. Megan Heere, from Temple University School of Medicine, did a show-and-tell with a BABYBOX , filled with educational materials and needed baby supplies, that is being used to encourage a safe sleep environment for infants. This caused much excitement as participants explored the box contents and discussed how it is being used at Temple.
Our annual meeting included a thank you to Esther Chung who has co-chaired the SIG for the past three years and a welcome to Jaspreet Loyal who will now be co-chair for a three-year term.
|Patient and Family Centered Care|
We had another great SIG session at PAS this year. Our joint SIG session with the Medical Informatics/Electronic Health Records SIG, "Patient-Centered Care through Health IT," highlighted ways to promote patient and family engagement in care and research using health IT tools, such as patient portals and telehealth. The session included a presentation from Dr. Alex Fiks on the state of patient portals in pediatrics and Dr. Peter Margolis who shared a structure for engaging patients and families through a research collaborative. We also had productive small group breakout sessions that allowed participants share their experiences and ideas implementing and using these technologies. Thank you to all who attended the SIG session!
If you have any feedback or ideas for future PAS PFCC topics or have ideas for collaboration within the PFCC SIG, please feel free to email Michelle Kelly (firstname.lastname@example.org) or Alisa Khan (email@example.com) We look forward to seeing you next year at PAS!
|Ethics Essay Contest at Ethics SIG|
Announcement: Ethics Essay Contest at Ethics SIG
Dear Pediatric Residents and Fellows of all Subspecialties in Pediatrics,
We are pleased to announce the sixth APA Ethics Special Interest Group (SIG) Essay Contest.
The contest is open to all pediatric residents and pediatric subspecialty fellows (including pediatric surgical fellows). Essays should focus on the ethical issues that residents and fellows face while caring for patients. Topics may include but not limited to personal narratives of ethical dilemmas faced in training or practice or scholarly presentations of issues related to organizational, interprofessional or global health ethics.
Essays should be between 800 to 1600 words. Essays longer than 1700 words will be disqualified without review. Essays must be original and unpublished works. If multiple authors, the award will be shared. All co-authors should provide demographic information (training status) and role in manuscript preparation.
Two awards will be offered. Awards can only be used as travel awards to attend the PAS meeting.
1st Place - $200
2nd Place - $100
The winning essays will be read at the PAS meeting in San Francisco and will be published in APA website as part of Ethics SIG newsletter in July 2017. If the resident or fellow will be attending PAS in San Francisco they may present their paper themselves.
Deadline: March 10, 2017
Submit essays to: firstname.lastname@example.org
We wish you all the best in your writings in ethics!
Zeynep Salih, M.D., MA
Indiana University School of Medicine
Riley Hospital for Children
Adrian Lavery, MD, MPH
Loma Linda University
Winning Essays for Ethics SIG Ethics Essay contest-2016
First prize winner: "End of Life Care Before Birth"
Phoebe Danziger, MD
Department of Pediatrics & Communicable Diseases
University of Michigan C.S. Mott Children's Hospital
End of Life Care Before Birth
On the last day of my third year of medical school, I learned that my pregnancy was complicated by an obstructive uropathy. I was 19 weeks pregnant, and we chose to terminate the pregnancy, an experience I have written about previously. My husband and I considered the fetus our baby, our son-to-be, and we experienced our decision to end his life in utero as the most profound medical and parenting decision we had ever made.
Now, as a pediatrician-in-training and the mother of three healthy daughters, I think frequently about our son, and the decision we made. With every child on the inpatient census with posterior urethral valves; with every well-child exam I schedule for my daughters; with every elevator ride I share with expectant parents who solemnly exit on the floor that houses the hospital's fetal diagnostic center, I think of our baby. I think of what color his fuzzy, sweet-smelling hair would have been, and how old he would be if he had survived. I think about how his brief existence is shaping me as a pediatrician, and I wonder if I would even be on this clinical path at all, a path already challenging enough with a young daughter, if we had continued the pregnancy. I wonder if we made the right decision for our baby and for our family.
The issues surrounding fetal anomalies and pregnancy termination are currently being debated with urgency and vigor on a national level. Ohio is poised to become the second state in the nation to ban abortion when Down Syndrome has been diagnosed prenatally, following North Dakota, which prohibits termination of any pregnancy with a "genetic abnormality" or "a potential for a genetic abnormality." Legislation has been introduced across the country prohibiting termination prior to 20 weeks gestation, often without exception for fetal anomalies. In many states, terminations can now be funded only with private insurance and if an "abortion rider" has been purchased in advance.
As advances in perinatology and neonatology expand the boundaries of what is possible in the perinatal period, the ethical questions that arise continue to elicit passionate, often diametrically opposed opinions. How do we define the ethical use of assisted reproductive technologies and prenatal diagnostic techniques? What is the role of pregnancy termination for fetal anomalies in medicine and in society? What is the scope of "end-of-life" decision-making in the perinatal period? What are the roles and obligations of physicians, and pediatricians in particular?
A paradigm shift is needed in order to forge a more sustainable and ethical approach to these complex and multifaceted issues. First, I propose that the distinctions often used as ethical and practical guideposts in the perinatal period - viability and pre-viability, fetus and neonate - be deemphasized in the setting of fetal anomalies. These distinctions are intuitive, morally rooted, and frequently helpful, but a dogmatic reliance on such dichotomies contributes to suffering and inequality.
Second, the concept of "best interest" in these cases must be explicitly broadened to incorporate the significance of the fetus's mother, family, and larger community. Third, the tension between the existence of certain perinatal interventions and decisions to use, forego, or withdraw them must be more transparently addressed. Finally, pregnancy termination must be recognized as falling within the scope of end-of-life decision-making and palliative care for some families, while acknowledging that this raises difficult questions about the roles and obligations of physicians.
Perinatal policy and practice focus strongly on the concept of viability, the potential to survive outside of the uterus. While there is robust discussion of certain ethical issues related to viability, such as decision-making at the margin of gestational viability, what is less explicitly discussed is the utility of the concept at all in the context of fetal anomalies. For fetuses with severe anomalies, extensive medical intervention may be required to allow for survival outside of the uterus. The use of such interventions, and the associated risks and benefits, carry different meanings and implications for families. Some treatments utilized in the perinatal period, such as neonatal dialysis, fall into a gray zone regarding when they are appropriate or obligatory to offer, and when they may be ethically declined. Thus, when survival may depend on extensive medical intervention with an uncertain risk-benefit profile, the concept of viability is only marginally useful.
From a practical standpoint, when pregnancy termination is restricted beginning at 20 weeks gestation or "viability," this is precisely the point at which many major anomalies are being diagnosed, as professional guidelines recommend a fetal anatomic survey at 18 to 20 weeks gestation. Families may be forced to make extremely high-stakes decisions under severe time pressure, with incomplete information. Delaying a decision in order to observe more of a condition's natural progression, to pursue further testing, or simply to reflect, may result in a drastic reduction in available choices. There is also the potential for significant socioeconomic and educational disparities, as individuals with lower health literacy may not comprehend the potential significance of obtaining timely prenatal diagnostic testing, and families may not have the resources to travel in a timely manner to obtain the desired medical care.
Just as viability is viewed as a critical turning point, a firm distinction is drawn between the fetus and the neonate. As a society we generally afford increasing recognition of personhood and rights with advancing gestational age and with birth, an approach that is overall reasonable and principled. A more humanistic and less mechanical perspective, however, suggests that while a neonate may technically be physically independent, the infant may be considered inextricably intertwined with its mother, its family, its community, and its culture in many ways. This is especially salient when considering a neonate with severe anomalies, whose survival depends on replacing the prenatal physiological dependence on its mother with the postnatal reliance on intensive medical care.
Continuing a pregnancy complicated by severe anomalies can have significant physical, psychological, and socioeconomic effects on mothers and families. In addition to concerns about the primary experience of their child, families may have concerns about the non-trivial risks associated with pregnancy and delivery, the emotional impact of continuing a pregnancy with a severely ill fetus, the psychological impact on siblings, logistical and financial details related to the need for intensive medical care at a tertiary care center, and the overall wellbeing of the family. Different families prioritize these factors differently, but the reality is that these perinatal decisions do not occur in a moral vacuum. For some families, the "best interest" of the fetus rightfully includes careful consideration of the best interest of the mother and the family.
Perinatal hospice and adoption are sometimes proposed as more just alternatives to pregnancy termination, often with reference to beliefs about fetal capacity for pain, establishment of personhood, and societal discrimination against disability. Conversely, many arguments in favor of more liberal abortion policy deemphasize the perceived humanity of the fetus. What all of these arguments miss, however, is that for many families, the humanity of the fetus with severe anomalies is a primary motivating factor in considering or choosing termination. For these families, termination is not a choice that reflects a devaluing of the fetus, or a disavowal of the worth or humanity of individuals with medical disabilities or differences. Instead, it is a decision that represents a complex calculus about how to most humanely consider and balance consideration for the fetus with considerations about other members of the family. Advocating for compulsory pregnancy continuation is based on a belief that life and survival must be valued above all else, a belief that is not universally shared and that strips parents of the autonomy to make medical decisions for their fetus based on their careful determination of the best interest of their fetus and their family.
Some point to the fundamental difference between withdrawing or withholding life-prolonging care, versus pregnancy termination as an active procedure intended to cause fetal demise. The accusation of "playing God" is sometimes leveraged. The provision of intensive perinatal care is not a passive act either, however, and in that sense attempting extensive intervention could also be considered "playing God." The potential pain and suffering associated with life-prolonging medical interventions is not incontrovertibly more noble or just than the potential pain and suffering associated with termination.
For some families, utilizing available medical options is a meaningful and valid choice. Life-prolonging interventions may allow a family to gain more information through a trial of therapy, to prevent complicated grief about "giving up without trying," or to shape the quantity and quality of their time with their child. A recent study by Annie Janvier and colleagues of families of children with trisomy 13 and 18 concluded that many families find deep meaning and satisfaction in pursuing certain life-prolonging measures. This is an important challenge to traditional paternalistic assumptions that there are some lives that are "not worth living." However, there is a risk of idealizing and glorifying such decisions, thereby perpetuating deeply entrenched forms of sexism and discrimination, as the meaning, satisfaction, or stress derived from such situations may be vastly different for a single mother with limited resources and secular beliefs, as compared to a religious, financially comfortable two-parent household with a mother who does not work outside the home.
What, then, is the role of the pediatrician in all of this? Reasonable individuals, physicians and non-physicians alike, possess vastly different opinions about fetal anomalies and pregnancy termination, opinions rooted in different ideas of compassion and justice. At times, the primary role of the physician may not be to heal, or save, or fix, but rather to help families navigate these murky and painful boundaries. We made the decision for our son to live and die knowing only the warmth and safety of my body; for us, it was the most right and just decision in a situation that was impossibly wrong. As physicians, we must vehemently defend the rights of families to make their own decisions; to define what constitutes the "best interest" of their own fetus and family; and to guide, in concert with the medical team, the meaningful use of medical intervention, whether life-prolonging or life-ending.
Second prize winner: "The Starfish Problem"
Bryan Sisk, MD
Pediatrics Resident, PL3
St. Louis Children's Hospital
The Starfish Problem
"Me duele los riñones," said the weathered old woman. Her face winced with deep lines as she pointed her thumb toward her lower back where she believed her kidneys were. She was the first patient of the day in the small Andean village, and a long line of dusty patients was already growing outside. "Aquí?" I asked as I palpated up and down her spine. She winced again as I pressed the muscles in her lower back. The diagnosis was lumbago, lower back pain, likely due to overuse and lack of stretching. Over the month of our medical mission trip, this was the most common complaint from patients. As a medical student at the time, I had memorized the spiel from my attending physician, even with my limited Spanish vocabulary. Avoid carrying heavy bags on your back. Bend with your knees, not at the waist. Stretch in the mornings and in the evenings. I showed her some exercises and asked her to practice with me. She suspiciously sat with me on the floor and twisted and turned. When we were done, I handed her a baggy of ibuprofen tablets and sent her on her way. She smiled at me as she slung a heavy burlap sack over her shoulder and walked off. I signaled for the next patient to come. It was a middle aged man with a sun-hardened face. He walked with his right hand pressed against his back, wincing as he slumped into the plastic chair across from me. "Los riñones?" I asked as I readied my next baggy of ibuprofen.
We had spent the past month visiting different villages throughout the Sacred Valley of the Peruvian Andes on a short-term medical mission, setting up makeshift clinics in whatever space was available. We had used churches, single-room school houses, even tents. Each morning, we woke before dawn, carried supplies to the bus station and caravanned to a different town. The roads were narrow and winding, offering beautiful views of the valley just beyond the thousand foot drop-offs. There were no guard rails or emergency vehicles. There was only worry and prayer.
As the day progressed, patients continued to cycle through our clinic, with diagnoses ranging from respiratory infections to arthritis to probable heart failure. One patient presented with craniofacial abnormalities and obvious developmental delays. I thought the diagnosis was untreated congenital hypothyroidism, but the parents were concerned that she was a machu, the spawn of a demon that secretly impregnated the mother while she was sleeping.
The last patient of the day was a six-year-old boy brought in by his mother for a checkup. He walked in barefoot, leaving footprints in the grime that had accumulated on the cement floor. His belly was slightly distended and he looked anxious. The mother spoke quickly and softly, but I was able to snatch the words gusano and las heces, worms in his stool. I listened to his chest, pressed on his belly and gave his mother a baggy of vitamins, anti-parasitic medicine and a toothbrush. A few minutes later as I helped to pack up our supplies, I saw the boy outside waving his toothbrush around like a sword and running it through the dirt. I wondered what would happen to these people once the baggies ran empty the next month.
With the last of the supplies packed securely in the rear of the bus, we started our three-hour-ride back to the hotel. I watched out the window as our patients from earlier in the day returned to their normal lives. Entire families worked in the fields, their eyes squinted against the sunlight and gritty wind. A man was driving a wooden plow behind two oxen. An old woman was whipping a bull that was a full foot taller than her with a long switch. One old man, probably in his seventies, was carrying a bushel of green wheat fresh from the ground on his shoulders. The bus curved around the mountainside and the town disappeared, like we had never been there. I was left wondering if we had done any good, if our efforts were worth it, or worse if we had actually caused more harm than good.
As I watched the town fade from view, an old parable came to mind. There was a beach littered with starfish that had been stranded by the receding tide. A young boy was running up and down the beach, scooping up starfish and throwing them back to the water. An old man watching called out to the boy. Why are you wasting your energy? There are too many. You can't save them. The young boy paused and stared at the old man, holding a starfish to the sky. At least I can save this one. And he tossed the starfish back to the ocean. When I had first heard this story, I thought assuredly the young boy was right. You have to keep hope in the face adversity, and you have to strive to help those in need. Lately, I had begun to wonder if the old man had a point. Or perhaps another character was needed in the story, someone to stop and ask why the starfish were being beached in the first place.
There was also a more modern and worrisome starfish problem that came to mind. In the recent past, the Great Barrier Reef off the coast of Australia was being threatened by hordes of hungry starfish that had an appetite for corals. Some well-meaning fishermen netted masses of starfish and cut them in half, trying to thin the herd. They dumped the buckets of mangled starfish back into the sea and rinsed the blood from their hands, feeling a sense of accomplishment. Little did they know that this species was able to regenerate lost limbs and each half turned into a new, whole starfish. After significant effort, they had doubled the severity of the problem. The harder they worked, the worse things got. I began to wonder if our efforts were multiplying our problems. Were there dangers of prescribing medications without any plan for follow-up? Was our medical advice incompatible with their necessary lifestyle? Did our actions undermine the authority of the local physicians who would remain after we left? Did our mere presence place a greater strain on their limited resources?
While there has been extensive debate regarding the ethics of international clinical research, discussion on the ethics of international medical volunteerism has been sparse.1-3 This disparity may be due in part to the belief that medical mission work is intrinsically altruistic and therefore intrinsically ethical.4 Unfortunately, this viewpoint does not encourage the critical ethical appraisal of short-term medical mission trips. Nor does it encourage forethought to ensure that short-term missions are not "self-serving... ineffective... or costly."4 As international health grows in popularity, short-term work is being further incorporated into all levels of medical education. Assuredly, the experiences that trainees gain from these trips will bolster their understanding of disparity in the world, and will hopefully help them to pass on the flame of altruism to their colleagues back home. However, the question remains as to whether the benefits of these trips outweigh the risks, and who is the primary beneficiary, the trainee or the patient. For example, some have questioned the ethics of medical trainees treating vulnerable populations, especially in areas beyond their expertise.5 Others have pointed to the potential lack of sustainability of changes after the mission workers leave, and question whether resources could be better utilized to foster lasting change.6 Perhaps rather than spending money on airfare, room and board for a volunteer, the money could be used to improve water sanitation efforts or could support the local physician who provides a lasting presence in the community.
As a medical trainee, it is tempting to sign up for a short-term medical mission with the assumption that our participation is inherently a good thing. We want to get our hands dirty in the gritty reality of disparity around the world. We want to be great physicians and to do great things. However, as in other parts of medical training, we ought to turn a critical eye to the risks and benefits of these interventions. Ill-conceived missions can lead to real harms: the child who becomes ill after eating an entire baggy of gummy vitamins, thinking they were candy; the post-operative patient who has insufficient follow-up for a complication; the local physician whose patients prefer to be seen by the foreign doctors. Good intentions are not enough to ensure good outcomes.
Certainly, there are some short-term medical missions that are well-structured and part of a greater plan that can lead to positive changes, but just as assuredly there are poorly organized, poorly conceived trips that harm the very people they are trying to help. As such, there are several important questions that ought to be asked prior to planning and implementing these trips. Was the mission planned in collaboration with the community being served? Will our presence help the community, or will it place an undue burden on already scarce local resources? Will any changes be sustainable after we leave? How will we know if we are helping or hurting? Is this primarily for us or for them?7 Although this conversation has begun to smolder in the literature, it must become louder and more inclusive in order to ensure the realization of our good intentions. Careful ethical scrutiny in the planning and implementation of short-term medical missions can help to ensure that our efforts are not for nothing. It is one thing to throw a few starfish back to the sea. It is quite another to impart real and lasting change.