Citation: WF Ferguson and DM Keller. Training Faculty for Cultural Teaching. In S Garrison and S Bloom (eds.) Cultural Competency in Medical Education: A Guidebook for Schools. Health Resources and Services Administration, www.hrsa.gov, Publication No. BHP00208. Sept 2004. p. 15-22.

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Citation: DM Keller. The Community as Teacher in S Fisch (ed.) Pediatric Education in Community and Office Settings Starter Kit. American Academy of Pediatrics/Council on Community Pediatrics. 2007. Link to book on publisher's website

Citation: DM Keller. The Case of the Country Pediatrician. In R Samuels and W Bithoney (eds.), Serving the Underserved Curriculum Project, Posted on Serving the Underserved: Rural Health website (http://www.servingtheunderserved.org/sused.html).

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PARTICIPANTS AND METHODS: Faculty members and residents at Massachusetts' 5 pediatric residency programs were interviewed to identify current curricula and teaching methods related to care of CYSHCN. In addition, residents were surveyed to quantify these concepts.

RESULTS: Thirty-one faculty members and 25 residents were interviewed. Most exposure to CYSHCN was reported to occur in inpatient settings. However, most formal teaching about CYSHCN was described as occurring in the ambulatory setting. Promising educational strategies included home and community visits, inclusion of CYSHCN in resident continuity panels, and simulation and role-playing. Overall, the programs had little training emphasis on the lives and needs of CYSHCN and their families outside the hospital setting. Twenty (80%) of the residents interviewed completed the written survey instrument. They noted a high degree of comfort in caring for CYSHCN in various settings and involving families in decision-making about their child's care but expressed less comfort in identifying community resources and collaborating with community agencies and schools.

CONCLUSIONS: Programs offer a variety of successful educational and clinical experiences related to the medical home and CYSHCN. The results of our study indicate that residents and faculty members believe that residents would benefit from more formal training opportunities to learn directly from families and community representatives about caring for CYSHCN.

METHODS: Project directors from 149 community-based programs funded from 1989 to 2003 through the Healthy Tomorrows Partnership for Children Program were surveyed regarding their project experience with evaluation and documentation of project outcomes and the current status of their project.

RESULTS: Program directors from 123 (83%) programs completed the survey. Despite barriers to the evaluation process, 83% of the respondents indicated that their evaluations produced useful information. Programs that were described by respondents as "well evaluated" were more likely to report that the evaluation was implemented as planned and that the evaluation included outcome measures. Projects were more likely to be sustained in their original form when at least 1 outcome was reported on the survey.

CONCLUSIONS: Evaluation of community-based programs, although challenging, is beneficial to project success and sustainability. Policy makers and funding agencies should consider ways to encourage community partnerships to incorporate evaluation into their planning process.

SETTING: Sixteen nonoverlapping Massachusetts communities enrolled in a community intervention study on appropriate antibiotic use.

DESIGN: Pediatricians, family physicians, and a random sample of parents of children less than 6 years old were surveyed. Parents predicted what their satisfaction would be with initial observation of an ear infection without antibiotics if suggested by their physician and concerns they would have regarding this watchful-waiting approach. Physicians reported the frequency with which they use this approach in children less than or = 2 years and those less than 2 years old. Separate multivariable models identified factors independently associated with parental satisfaction and with frequency of self-reported use by physicians. All models accounted for clustering of responses within communities.

RESULTS: Two thousand fifty-four (40%) parents and 160 (58%) physicians responded. Of the parents, 34% would be somewhat or extremely satisfied if initial observation was recommended, another 26% would be neutral, and the remaining 40% would be somewhat or extremely dissatisfied. The multivariable model showed lower parental education (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.35, 0.71, for high school education or less compared with college graduation) and Medicaid enrollment (OR: 0.77; CI: 0.57, 1.0) was associated with lower predicted satisfaction. Higher antibiotic-related knowledge (OR: 1.2; CI: 1.1, 1.3, per question correct), belief that antibiotic resistance is a serious problem (OR: 2.3; CI: 1.8, 2.8), and reporting feeling included in medical decisions (OR: 1.4; CI: 1.1, 1.7) all were independently associated with higher predicted satisfaction. Thirty-eight percent of physicians treating children greater than or = 2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. In a multivariable model, only more years in practice (OR: 0.96; CI: 0.93, 0.99) was associated with a decreased likelihood of occasional or more-frequent use of watchful waiting (compared with those who never use initial observation). However, a secondary model that combined occasional users with nonusers (compared with those reporting use sometimes or more often) identified several correlates of use of observation: years in practice (OR: 0.95; CI: 0.91, 0.99), family medicine specialization (OR: 4.5; CI: 1.9, 11), belief that antibiotic resistance is a significant problem (OR: 4.3; CI: 1.3, 14.5), and practice in a community receiving a judicious antibiotic-use intervention (OR: 3.5; CI: 1.3, 9.1).

CONCLUSIONS: A majority of physicians reported at least occasionally using initial observation, but few use it frequently. Many parents have concerns regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions. Substantial change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media.

OBJECTIVE: To identify an operational definition of advocacy, as well as knowledge, skills, and attitude objectives for advocacy training in pediatric residency programs.

METHODS: Professionals experienced in pediatric advocacy and training (n = 53) were invited to participate in a sequence of surveys to define the content of a pediatric residency advocacy curriculum that would result in acquisition of appropriate knowledge, skills, and attitudes related to advocacy for children. Three rounds of surveys were distributed, collected, and analyzed using a modified Delphi technique, in which the results from an antecedent survey were used to refine responses in a subsequent survey.

RESULTS: Participants (n = 36), comprising a group of experienced leaders with diverse training and experience in child advocacy and resident education, created a consensus definition for advocacy. They initially identified 179 possible objectives for advocacy curricula. Through the iterative process of the Delphi technique, 32 of those objectives were identified as necessary for inclusion in a child advocacy curriculum for pediatric residents.

CONCLUSIONS: Using a modified Delphi technique, a group of experienced leaders in pediatric advocacy were able to reach consensus on an operational definition of child advocacy and a set of objectives for a resident advocacy curriculum. Programs may use these findings to assist in developing an advocacy curriculum based on their own faculty assets and community resources.

RECENT FINDINGS: Coordination is highly dependent on effective communication within the health care system and between the health care system and the larger community. While coordination may best be undertaken at the level of the physician practice, a team approach involving non-physician staff and families as primary participants may be the best option in many cases. More attention is being paid at the health policy level to the implementation of coordination of care, although solutions to reimbursement barriers have yet to be implemented. Considerable progress on methods to improve care coordination in the primary care practice setting has been made recently. Many of these efforts have used quality improvement techniques adapted from the business world. Emerging measures of the process of care coordination are also being developed, although few studies have been published to date showing a positive impact of care coordination.

SUMMARY: The value of coordination of care as an essential part of medical care for children with special health care needs is becoming widely recognized. Methods to implement it within pediatric primary care practices are being developed, although more data demonstrating its value are needed to inform policy changes.