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Background and Objectives: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites., Methods: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents., Results: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged., Conclusions: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: While many Area of Focused Competency (AFC) Diplomas are available to those who have completed Pediatric residency training, it is not known which competencies are enhanced within each AFC discipline. Our objective was to determine which CanMEDS roles were targeted by existing AFCs available to those who have completed Pediatric residency training and identify gaps within CanMEDs roles that may be fulfilled by the development of new AFCs., Methods: A qualitative study was undertaken using document analysis methodology to compare CanMEDS competencies across AFCs available to those with Royal College examination eligibility or certification in Pediatrics. RCPSC Competency Training Requirements documents were used to compare and contrast the competencies in each AFC with competencies established in Pediatric residency training. Key and Enabling Competencies were compared for each CanMEDS role to identify differences., Results: Ten AFCs were identified with eligibility requirements including Royal College examination eligibility or certification in Pediatrics. All 10 AFCs included at least one new Medical Expert competency, for a total of 42 unique competencies in this role across all AFCs. The Scholar role had only 10 new competencies across seven AFCs, while only one AFC added a single unique competency in the Collaborator role., Conclusions: The majority of new competencies contributed by AFCs lie within the CanMEDS role of Medical Expert. The Scholar and Collaborator roles have the least differences when comparing competencies of existing AFCs to those competencies established in Pediatric residency training. Developing additional AFCs that offer advanced skills in these roles may help close this gap within the discipline of Pediatrics., Competing Interests: None of the authors have any conflicts of interest due to financial or personal relationships that could potentially bias their work., (© 2023 Agarwal, Conejero Muller, Atkinson, Bismilla; licensee Synergies Partners.)

Background: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed., Objective: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication., Design: Prospective Type 2 Hybrid effectiveness implementation study., Settings and Participants: Residents from diverse specialties across 32 hospitals (12 community, 20 academic)., Intervention: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews., Main Outcome and Measures: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality., Results: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic)., (© 2022 Society of Hospital Medicine.)

Introduction: Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs., Methods: Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop., Results: Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs., Discussion: The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs., (© 2022 Lewis et al.)

Background: High-stakes conversations are frequent in Medical Genetics. News shared is often perceived as "bad" and can lead to patient hostility. Breaking bad news (BBN) is therefore a challenging clinical task for physicians and is often included as a foundational skill in medical education. The methods of teaching this skill are variable, with no widely accepted standard. We propose the use of simulation as a safe and effective training tool., Approach: Medical Genetics residents participated in a 4-week curriculum on BBN and de-escalating patient hostility and anger. The curriculum consisted of (1) a standardised patient simulation scenario requiring the disclosure of abnormal prenatal test result to a hostile patient, (2) coaching and feedback by genetic counsellors (GCs), (3) reflective exercises, and (4) workshops on de-escalation techniques. Trainees completed a postsimulation survey and postencounter reflection forms. Written comments on the survey and the reflections were analysed for themes., Evaluation: Six junior and four senior residents participated in this curriculum innovation. Analysis of reflections revealed that simulation coupled with the genetic counsellor's (GC) timely feedback and reflection exercise were good education strategies for practicing BBN and de-escalation techniques in a challenging counselling situation. Most of the trainees felt that this teaching approach was successful and should be used for future training., Implications: Simulation can help prepare Medical Genetics trainees deliver difficult news and successfully de-escalate a hostile patient encounter. Consideration should be given to counselling and de-escalation simulations as a useful addition to standing curricula for Medical Genetics trainees., (© 2022 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objectives: Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula., Method: We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice., Results: Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement., Conclusion: Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This article was migrated. The article was marked as recommended. Met with the challenge of physical distancing during the escalation of the COVID-19 pandemic, medical educators rapidly pivoted their educational repertoires to virtual learning platforms. While selection and utilization of virtual platforms may vary amongst medical educators, elements of evidence-based educational theories, collaborative learning, and learner engagement are essential to the success of learning for any format. In this piece we outline 12 tips for virtual learning, drawing on concepts from available literature and our collective experience as medical educators. As virtual learning platforms continue to evolve, medical educators should leverage different modalities, without compromising the fundamental elements and theories that promote learner success., (Copyright: © 2021 Lewis K et al.)

Introduction: The field of Paediatric Medicine has grown tremendously over the last two decades. Several niche areas of practice have emerged, and opportunities for focused training in these areas have grown in parallel. The landscape of 'General Paediatric Fellowship' (GPF) Programs in Canada is not well described; this knowledge is needed to promote standardization and high-quality training across Canada. This study explores the structure and components of existing GPFs in Canada and identifies the interest and barriers to providing such programs., Methods: A questionnaire was created to explore the landscape of GPF Programs in Canada. Invitations to participate were sent to leaders of General Paediatric Divisions across Canada, with a request to forward the survey to the most appropriate individual to respond within their local context., Results: A total of 19 responses (95%) representing 17 different Canadian universities were obtained. Eight universities offered a total of 13 GPF Programs in 2019, with one additional university planning to start a program in the coming year. Existing programs were variable in size, structure and curriculum. Most programs identified as Academic Paediatric Programs, with an overlap in content and structure between Academic Paediatrics and Paediatric Hospital Medicine programs. The majority of respondents felt there was a need for GPF Programs in Canada but cited funding as the most common perceived barrier., Conclusion: A growing number of GPF Programs exist in Canada. Current fellowship programs are variable in structure and content. Collaboration between programs is required to advance GPF training in Canada., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

Background: The Accreditation Council for Graduate Medical Education (ACGME) Milestone projects required each specialty to identify essential skills and develop means of assessment with supporting validity evidence for trainees. Several specialties rate trainees on a milestone subcompetency related to working in interprofessional teams. A tool to assess trainee competence in any role on an interprofessional team in a variety of scenarios would be valuable and suitable for simulation-based assessment., Objective: We developed a tool for simulation settings that assesses interprofessional teamwork in trainees., Methods: In 2015, existing tools that assess teamwork or interprofessionalism using direct observation were systematically reviewed for appropriateness, generalizability, adaptability, ease of use, and resources required. Items from these tools were included in a Delphi method with multidisciplinary pediatrics experts using an iterative process from June 2016 to January 2017 to develop an assessment tool., Results: Thirty-one unique tools were identified. A 2-stage review narrowed this list to 5 tools, and 81 items were extracted. Twenty-two pediatrics experts participated in 4 rounds of Delphi surveys, with response rates ranging from 82% to 100%. Sixteen items reached consensus for inclusion in the final tool. A global 4-point rating scale from novice to proficient was developed., Conclusions: A novel tool to assess interprofessional teamwork for individual trainees in a simulated setting was developed using a systematic review and Delphi methodology. This is the first step to establish the validity evidence necessary to use this tool for competency-based assessment., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Purpose: To report on the evolution of simulation-based training (SBT) by identifying the composition and infrastructure of existing simulation fellowship programs, describing the current training practices, disclosing existing program barriers, and highlighting opportunities for standardization., Method: Investigators conducted a cross-sectional survey study among English-speaking simulation fellowship program directors (September 2014-September 2015). They identified fellowships through academic/institutional Web sites, peer-reviewed literature, Web-based search engines, and snowball sampling. They invited programs to participate in the Web-based questionnaire via e-mail and follow-up telephone calls., Results: Forty-nine programs met the inclusion criteria. Of these, 32 (65%) responded to the survey. Most programs were based in the United States, but others were from Canada, England, and Australia. Over half of the programs started in or after 2010. Across all 32 programs, 186 fellows had graduated since 1998. Fellows and directors were primarily departmentally funded; programs were primarily affiliated with hospitals and/or medical schools, many of which had sponsoring centers accredited by governing bodies. Fellows were typically medical trainees; directors were typically physicians. The majority of programs (over 90%) covered four core objectives, and all endorsed similar educational outcomes. Respondents identified no significant universal barriers to program success. Most directors (18/28 [64%]) advocated standardized fellowship guidelines on a national level., Conclusions: Paralleling the fast growth and integration of SBT, fellowship training opportunities have grown rapidly in the United States, Canada, and beyond. This study highlights potential areas for standardization and accreditation of simulation fellowships which would allow measurable competencies in graduates.

Background: The I-PASS Handoff Study found that introduction of a handoff bundle (handoff and teamwork training for residents, a mnemonic, a handoff tool, a faculty development program, and a sustainability campaign) at 9 pediatrics residency programs was associated with improved communication and patient safety., Objective: This parallel qualitative study aimed to understand resident experiences with I-PASS and to inform future implementation and sustainability strategies., Methods: Resident experiences with I-PASS were explored in focus groups (N = 50 residents) at 8 hospitals throughout 2012-2013. A content analysis of transcripts was conducted following the principles of grounded theory., Results: Residents generally accepted I-PASS as an ideal format for handoffs, and valued learning a structured approach. Across all sites, residents reported full adherence to I-PASS when observed, but selective adherence in usual practice. Residents adhered more closely when patients were complex, teams were unfamiliar, and during evening handoff. Residents reported using elements of the I-PASS mnemonic variably, with Illness Severity and Action Items most consistently used, but Synthesis by Receiver least used, except when observed. Most residents were receptive to the electronic handoff tool, but perceptions about usability varied across sites. Experiences with observation and feedback were mixed. Concern about efficiency commonly influenced attitudes about I-PASS., Conclusions: Residents generally supported I-PASS implementation, but adherence was influenced by patient type, context, and individual and team factors. Our findings could inform future implementation, particularly around the areas of resident engagement in change, sensitivity to resident level, perceived efficiency, and faculty observation., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Importance: Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection., Objective: To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports., Design, Setting, and Participants: We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient., Main Outcomes and Measures: Error and AE rates., Results: Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates., Conclusions and Relevance: Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs.The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.

Background: The Royal College of Physicians and Surgeons of Canada (RCPSC) objectives for training in pediatrics include 26 procedural skills, 11 of which are included in the final in-training evaluation report (FITER). The importance of each procedure for practice and the preparedness of pediatric residency graduates to perform these procedures are not known., Methods: A questionnaire was distributed to all pediatric residency program directors and members of the RCPSC Specialty Committee in Pediatrics (N = 21) in October 2010, requesting them to rate the perceived importance and preparedness of graduating pediatric residents in all procedural skills on a 5 point Likert scale, as well as the presence of a curriculum and documentation for each procedure. Mean importance and preparedness were calculated for each procedure., Results: Response rate was 16/21 (76 %). Perceived preparedness was significantly lower than importance for the majority of procedures (p < 0.05). Ten procedures had a high mean importance rating (>3) but a low mean preparedness rating (<3). Presence of a curriculum and documentation for procedures varied across centers, and their presence was correlated with both perceived importance and preparedness (p < 0.0001)., Conclusions: Many procedures in which pediatric residents are required to be competent by the RCPSC are felt to be important. Residents are not felt to be adequately prepared in several of the required procedures by the time of graduation. Procedures with high ratings of importance but low preparedness ratings should be targeted for curricular interventions.

Background and Objective: Medical education relies heavily on workplace learning where trainees are educated through their clinical experience. Few studies have explored trainees' perceptions of the educational value of these patient care experiences. The aim of this study was to identify pediatric patient characteristics that medical trainees perceive as educationally valuable., Methods: Over 2 months, trainees on pediatric inpatient wards ranked the perceived educational value of patients under their care on a 4-point bipolar Likert scale. Three patient characteristics were examined: complex-chronic and noncomplex-chronic preexisting conditions, difficult social circumstances, and rare diseases. Patient-level predictors of cases perceived as educationally valuable (defined as scores≥3) were examined by using univariate and multivariate analyses., Results: A total of 325 patients were rated by 51 trainees (clinical medical students [45%], first-year residents [29%], third-year residents/fellows [26%]). Rare diseases had a higher educational value score (adjusted odds ratio 1.76, 95% confidence interval 1.08-2.88, P=.02). Complex-chronic and noncomplex-chronic preexisting conditions and difficult social circumstances did not affect the perceived educational value., Conclusions: Trainees attribute the most educational value to caring for patients with rare diseases. Although trainees' perceptions of learning do not necessarily reflect actual learning, they may influence personal interest and limit learning from an educational experience. Knowledge of trainee perceptions of educational experience therefore can direct medical educators' approaches to inpatient education., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking., Methods: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events., Results: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time., Conclusions: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Background: The Royal College of Physicians and Surgeons of Canada (RCPSC) sets objectives for residency training, including many skills that may not be commonly performed in practice., Objective: To describe attitudes of residents enrolled in Canadian paediatric residency programs toward procedural skills training, including perception of importance and perceived proficiency of the RCPSC-required procedures., Methods: An anonymous electronic survey was distributed to all senior residents enrolled in Canadian paediatric residencies, using a five-point Likert scale to address procedural importance and corresponding proficiency. Data were analyzed using descriptive statistics, with Pearson correlation coefficients used to describe relationships among variables., Results: A total of 68 residents responded. Fifteen skills had a mean importance ≥4 (very or extremely important) and five skills had a mean rating <3 (somewhat or not important). Residents believed they were extremely or very proficient (mean rating ≥4) for three skills (bag-mask ventilation, lumbar puncture and chest x-ray interpretation). They reported 23 procedures for which they felt somewhat to not proficient (mean <3). The correlation between importance and proficiency was high (Pearson's correlation coefficient = 0.87). However, proficiency was significantly lower than importance (P<0.05) for the majority of procedures (88%). The largest gaps between importance and proficiency were observed for chest tube insertion, gathering evidence of child maltreatment, defibrillation and intraosseous insertion., Conclusion: Many, but not all, RCPSC-required procedures are believed to be important. Residents do not believe that they are adequately proficient in many of these procedures. Skills with the greatest gap between importance and proficiency may be targets for curricular interventions.

Background: On July 1, 2009, in Ontario the maximum period of continuous duty that residents were permitted to work was reduced from 28 to 24 hours. We evaluated the effect of regulation on residents in 3 eras: 2 before (2005 and early 2009) and 1 after (late 2009) the duty-hour reduction., Methods: On-call pediatric residents on pediatric medicine rotations prospectively recorded the numbers of patients (assigned and admitted) and the durations of direct patient care, documentation, staff supervision, and education attended. Sleep was measured with actigraphy., Results: The 51 residents worked 180 duty periods, were assigned a median of 6 (interquartile range: 4 -12) daytime patients and 24 (interquartile range: 19-30) overnight patients. Residents reported spending means of 239 minutes providing direct patient care, 235 minutes documenting, and 243 minutes sleeping and receiving 73 minutes of staff supervision and 52 minutes of education. From early 2009 to after duty-hour reduction, residents provided 47 fewer (19.6%) minutes of direct patient care (P = .056) and received 44 fewer minutes (60.3%) of supervision (P = .0005) but spent similar times documenting, receiving education, and sleeping. In early 2009, residents provided 73 more minutes (30.5%) of direct patient care (P = .0016), spent 63 more minutes (26.8%) documenting, and slept 105 fewer minutes (43.0%) (P = .0062) than in 2005., Discussion: After duty-hour reduction in 2009, we found reduced supervision and direct patient care. Comparison of the 2 periods before duty-hour reduction showed less sleep and longer patient contact in early 2009, which suggests that changes occurred without regulation.

This report describes a case of Hashimoto encephalopathy in an 11-year-old girl. She presented with features typical of this disorder including encephalopathy, seizures, and neuropsychiatric symptoms. Diagnosis was supported by an elevated thyroid-stimulating hormone level, a low levo-thyroxine level, and positive results for antithyroperoxidase antibody. Her response to typical treatment with levo-thyroxine was incomplete, requiring additional therapy with valproic acid and methylprednisone. Her course was further complicated by the development of acute psychosis. Treatment with risperidone was correlated with resolution of her psychosis and improvement in neuropsychiatric symptoms. Response to antipsychotic therapy has not previously been described in the pediatric population with Hashimoto encephalopathy. This case highlights the need for guidelines for the management of this rare disorder.