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Purpose Difficulty in recruiting and retaining community preceptors for medical student education has been described in the literature. Yet little, if any, information is known about community outpatient preceptors who have stopped or decreased teaching time with students. This study aimed to examine these preceptors' perspectives about this phenomenon. Method Using a phenomenology framework, this multi-institutional qualitative study used semistructured interviews with community pediatric preceptors who had stopped or reduced teaching time with medical students. Interviews were conducted between October 2017 and January 2018 and transcribed verbatim. Interviews explored factors for engaging in teaching, or decreasing or ceasing teaching, that would enable future teaching. An initial code book was developed and refined as data were analyzed to generate themes. Results Twenty-seven community pediatricians affiliated with 10 institutions participated. Thirty-seven codes resulted in 4 organizing themes: evolution of health care, personal barriers, educational system, and ideal situations to recruit and retain preceptors, each with subthemes. Conclusions From the viewpoints of physicians who had decreased or stopped teaching students, this study more deeply explores previously described reasons contributing to the decline of community preceptors, adds newly described barriers, and offers strategies to help counter this phenomenon based on preceptors' perceptions. These findings appear to be manifestations of deeper issues including the professional identify of clinical educators. Understanding the barriers and strategies and how they relate to preceptors themselves should better inform education leaders to more effectively halt the decline of community precepting and enhance the clinical precepting environment for medical students.

1. Catherine Krafft, MD* 2. Cynthia Christy, MD†,‡ 1. *Department of Pediatrics and 2. †Division of Pediatric Infectious Diseases, University of Rochester School of Medicine and Dentistry, Rochester, NY 3. ‡Rochester General Hospital, Rochester, NY * Abbreviations: CAP: : community acquired pneumonia EM: : erythema multiforme FDA: : Food and Drug Administration MIRM: : Mycoplasma pneumoniae– induced rash and mucositis PCR: : polymerase chain reaction SJS: : Stevens-Johnson syndrome Mycoplasma pneumoniae is a frequent cause of respiratory infections, including community-acquired pneumonia, in school-age children. However, as the science surrounding the diagnosis of this pathogen improves, our knowledge of its epidemiology, including asymptomatic carriage, and the management of this disease is evolving. After completing this article, readers should be able to: 1. Understand the microbiology and epidemiology of Mycoplasma pneumoniae infection. 2. Describe the variable clinical presentation of M pneumoniae infection and extrapulmonary manifestations. 3. Understand the difficulties associated with diagnosing infection with M pneumoniae and current recommendations for diagnosis. 4. Appropriately treat patients with suspected Mycoplasma infection. A 9-year-old girl presents to her pediatrician with a fever, decreased energy, and a cough for 10 days. She was initially evaluated 4 days ago when she had rhinorrhea, a cough, and decreased energy over the previous week. Her examination at that time was notable only for a mildly erythematous posterior oropharynx and nasal discharge. She was diagnosed as having a viral upper respiratory tract infection, and supportive care measures were recommended. Since that visit, her cough is more persistent and she has developed fevers. On examination her temperature is 100.8°F (38.2°C), heart rate is 100 beats/min, respiratory rate is 40 breaths/min, and oxygen saturation is 90% on room air. She is generally well-appearing. Her physical examination is remarkable for an erythematous posterior oropharynx, nasal discharge, and bilateral diffuse crackles on auscultation of her lungs. What is the next step in diagnosis and management? ### Microbiology Mycoplasma pneumoniae is a tiny, pleomorphic bacteria belonging to the class Mollicutes and is the smallest self-replicating bacteria pathogenic in humans, its only known host. M pneumoniae is unique in having no …

Background Acute otitis media (AOM) is the most frequent indication for antibiotic treatment of children in the United States. Its diagnosis relies on visualization of the tympanic membrane, a clinical skill acquired through a deliberate approach. Instruction in pediatric otoscopy begins in medical school. Medical students receive their primary experience with pediatric otoscopy during the required pediatric clerkship, traditionally relying on an immersion, apprentice-type learning model. A better understanding of their preceptors’ clinical and teaching practices could lead to improved skill acquisition. This study investigates how pediatric preceptors (PP) and members of the Council on Medical Student Education in Pediatrics (COMSEP) perceive teaching otoscopy. Methods A 30-item online survey was administered to a purposeful sample of PP at six institutions in 2017. A comparable 23-item survey was administered to members through the 2018 COMSEP Annual Survey. Only COMSEP members who identified themselves as teaching otoscopy to medical students were asked to complete the otoscopy-related questions on the survey. Results Survey respondents included 58% of PP (180/310) and 44% (152/348) of COMSEP members. Forty-one percent (62/152) of COMSEP member respondents identified themselves as teaching otoscopy and completed the otoscopy-related questions. The majority agreed that standardized curricula are needed (PP 78%, COMSEP members 97%) and that all graduating medical students should be able to perform pediatric otoscopy (PP 95%, COMSEP members 79%). Most respondents reported usefulness of the American Academy of Pediatrics (AAP) AOM guidelines (PP 95%, COMSEP members 100%). More COMSEP members than PP adhered to the AAP’s diagnostic criteria (pediatric preceptors 42%, COMSEP members 93%). The most common barriers to teaching otoscopy were a lack of assistive technology (PP 77%, COMSEP members 56%), presence of cerumen (PP 58%, COMSEP members 60%), time to teach in direct patient care (PP 46%, COMSEP members 48%), and parent anxiety (PP 62%, COMSEP members 54%). Conclusions Our study identified systemic and individual practice patterns and barriers to teaching pediatric otoscopy. These results can inform education leaders in supporting and enabling preceptors in their clinical teaching. This approach can be adapted to ensure graduating medical students obtain intended core clinical skills.

Tools to examine the effects of teaching interventions across a variety of studies are needed. The authors perform a meta-analysis of 24 randomized controlled trials evaluating the effects of teaching on medical students’ patient communication skills. Study quality is rated using a modified Jadad score, and standardized mean difference effect size ( d) measures are calculated. Fifteen of 24 studies have sufficient data for analysis. Students’ ability to establish rapport improves after teaching. The effects are large when the teaching intervention was small group discussion ( n = 5) or giving structured feedback on a student-patient interview ( n = 6). A similar effect of teaching is seen on student data gathering skills ( n = 5). Teaching medical students patient communication skills using small group discussion or providing feedback on a student-patient interview results in improvement in student performance.

The Council on Medical Student Education in Pediatrics (COMSEP) is the national group of the clerkship directors of the North American medical schools. Its 2005 annual meeting was held in Greensboro, NC, April 7 through 10, 2005. The mission of COMSEP is to foster excellence in pediatric undergraduate education and thus to improve the health care of children in North America. The theme for this year was "Releasing the Imagination: Encountering the Arts in Education." We had 2 plenary speakers, 2 extended preconference workshops (1 on "Qualitative Research" and 1 for new clerkship directors), and 20 other workshops on a wide range topics in medical student education and the arts in medicine. A special tribute session was also given to honor our friends, mentors, and colleagues, Richard T. Sarkin, MD, and Steven Z. Miller, MD, who died October 19, 2004 while traveling together to present their workshop on "Humanism in Medicine" as Arnold P. Gold Foundation Fellows. Before the meeting, the Research and Schol...

A randomized, controlled trial was conducted at a private university to determine whether students who received an informational letter (n = 366) would be more likely to receive a hepatitis B vaccination than students in a control group (n = 366). Surveys were conducted to determine the students' reasons for deciding to be vaccinated. Rates of hepatitis B immunization were significantly higher among students assigned to the intervention group (10.7%) than among the control group (1.9%). Vaccinated students were more likely than unvaccinated students to report having had 3 or more sexual partners in the past 6 months. Students at higher risk for hepatitis B infection were more likely than others to be vaccinated. Although the overall rate of immunization was low, informational letters about the hepatitis B virus and vaccine were found to be efficacious in increasing hepatitis B immunization rates among students in the setting of a concurrent educational campaign.

Objective. To determine whether gender, race (black or white), or level of parental education influenced serologic responses or reporting of clinical reactions after immunization with acellular (DTaP) or whole-cell (DTP) pertussis vaccine with diphtheria and tetanus toxoids combined. Methods. Healthy infants were prospectively randomized to receive one of 13 DTaP, Lederle DTP, or another DTP. Parents recorded the occurrence of adverse reactions for 2 weeks after each inoculation. Sera obtained before the first immunization and 1 month after the third immunization were analyzed for antibody to pertussis toxin, filamentous hemagglutinin, fimbriae, and pertactin (PRN). Chinese hamster ovary cell pertussis toxin neutralization assays were performed, and levels of agglutinating antibodies determined. Results. Prevaccination antibody levels did not differ by race, gender, or parental education. Postimmunization geometric mean titers (GMTs) were strongly and consistently associated with race. For both DTaP and DTP and for every included antigen, postimmunization GMTs were about twice as high for black as for white infants. Among DTaP recipients, these differences were significant for pertussis toxin, Chinese hamster ovary cell pertussis toxin neutralization assay, filamentous hemagglutinin, PRN, and agglutinins ; among the much smaller sample of WCL recipients, the differences achieved or approached statistical significance for agglutinins, PRN, and fimbriae. These findings were confirmed by regression analyses that controlled for gender, parental education, study site, and preimmunization antibody level. Reported reactions were not correlated with parental education level and showed no material correlation with gender. Black infants were reported to have had more pain than white infants after receiving WCL and DTaP and were reported to be more fussy after receiving WCL. Conclusions. The consistently higher postimmunization GMTs among black infants seems to be a real finding for which we have no explanation ; the infants did not significantly differ by race in vaccine assignment, preimmunization antibody levels, age at immunization, or interval from immunization to phlebotomy. These observations should be confirmed and further evaluated in future pertussis vaccine trials. Reported differences by race in pain and fussiness after receiving WCL might reflect chance, differences by race in the occurrence of reactions, or differences by race in the reporting of reactions. Pediatrics 1995 ;96 :584-587 ; acellular, antibody, diphtheria-tetanus-pertussis, vaccine, whole-cell, whooping cough.

The Council on Medical Student Education in Pediatrics continues its series on great clinical teachers, focusing on professionalism in practice. The Council on Medical Student Education in Pediatrics is in agreement with the Liaison Committee on Medical Education, Accreditation Council on Graduate Medical Education, and the CanMEDS Physician Competency Framework, that professionalism is essential to the practice of medicine, regardless of the level of training. Clinical teachers are in an excellent position to promote and assess professional behaviors in students but are often hesitant to address lapses in professionalism; however, addressing professionalism early is critical, as professional misbehavior in medical school is a major risk factor for subsequent censure by state medical boards.1 This article discusses tools and strategies for the assessment, remediation, and promotion of professionalism in medical students. Many practitioners say, “I know it when I see it,” but defining professionalism can be challenging. Professionalism is built on the principles of excellence, humanism, accountability, and altruism and is demonstrated through clinical competence, communication, and ethical understanding.2 Humanism and altruism encompass beneficence, respect, truthfulness, and placing the needs of the patient above one's own. Excellence and accountability include striving for high-quality patient care, making a commitment to lifelong learning, and exhibiting responsibility to duty. Professional maturity requires the development of these behaviors through deliberate practice so that they become the habits that define a good physician. Evaluating professionalism is the responsibility of every clinical teacher. Assessable components include adherence to ethical practice principles, effective interactions with patients and the people who are important to these patients, effective interactions with individuals within the health care system, reliability and accountability, and commitment to improvement.3 The development of professionalism in medical … Address correspondence to April O. Buchanan, MD, Department of Pediatrics, University of South Carolina School of Medicine, Greenville Hospital System University Medical Center, 701 Grove Rd, 4th Floor Balcony Suites, Greenville, SC 29605. E-mail: abuchanan{at}ghs.org

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature ≥39° C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae , 9 Haemophilus influenzae type b, 7 Salmonella , 2 Neisseria meningitidis , and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella ) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08,to 1.82, p =0.31). The five children with definite bacterial infections (three meningitls, one pneumonia, one sepsis) recelved amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p =0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p =0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Trichosporon beigelii, a ubiquitous yeast found in soil, causes superficial dermatologic infections in normal hosts and rare cases of disseminated disease among immunocompromised patients. Neonatal cases are exceptionally rare. We report a cluster of cases of T. beigelii infections in a tertiary care hospital in Rochester, NY, during May to July, 1991. Three cases occurred in very low birth weight premature infants (23 to 25 weeks of gestation), two of whom died. The organism was isolated from urine alone in one case, skin and blood in one case and blood, tracheal aspirate and central venous catheter tip in one case. In a fourth, full term infant with respiratory distress syndrome T. beigelii was grown only from a femoral central venous catheter tip with no clinical evidence of infection. An epidemiologic investigation was performed and the mode of transmission in this outbreak was not identified, although cross-infection was suspected in the initial two cases. Our isolates were inhibited but not killed by usually achievable concentrations of amphotericin B. T. beigelii may cause outbreaks of serious infection in neonatal intensive care units, especially among premature infants.

This resource is a workshop designed for health care educators interested in advancing their scholarship in medical education. The goal of this workshop is to provide participants with practical guidance for turning their educational service into scholarship. Through this workshop, participants will develop a firm understanding of the scholarship of application, one of the four types of scholarship outlined by Ernest Boyer in 1990. The scholarship of application involves service and the use of knowledge to solve problems of individuals or society. Examples of applying knowledge in medical education include curriculum development, clerkship restructuring, and development and implementation of evaluation tools or new programs. While medical educators typically engage in these activities, many do not recognize that such activities have the potential to qualify as scholarship. Participants in this workshop will have the opportunity to go through the process of moving an educational project through the steps necessary for it to qualify as high-quality scholarship, based on Glassick's six characteristics of scholarship. Finally, participants will have the opportunity to apply the characteristics of scholarship to their own educational endeavors and discuss opportunities for the dissemination of such work. Nearly all participants in the workshop rated it excellent in delivery, content, objectives met, interactivity, and overall effectiveness. Comments on the peer review feedback form indicated that the participants especially appreciated the systematic analysis of the concepts of scholarship of application as well as the time to discuss, reflect, and apply these concepts to specific examples so they could develop ideas for their own projects.

Objective: To determine if a nurse intervention guided by an immunization algorithm was associated with an increased use of immunization opportunities at non–well-child care visits. Design: A controlled intervention trial of an algorithm-guided nurse intervention during a 5-month period. The use of immunization opportunities at an intervention site was compared with the use at this site during the previous year (the retrospective control group) and with that at a similar pediatric practice during the same period (the concurrent control group). Study Population: Children aged 2 to 60 months at 2 hospital-based pediatric practices that serve children of families with low to moderate incomes in Rochester, NY. Results: During the study periods, 2814 study children in the 3 groups made 5464 visits for non–well-child care. The use of immunization opportunities for diphtheria-tetanus-pertussis vaccine, live oral poliovirus vaccine, and measles-mumps-rubella vaccine at intervention visits was significantly better than at the visits of the retrospective or concurrent control groups (range of odds ratios, 1.9-2.5). Conclusion: An algorithm-guided nurse intervention improved the use of immunization opportunities at non–well-child care visits. Arch Pediatr Adolesc Med. 1997;151:384-391

Background: There is a lack of clinical evidence that annual vaccination against influenza prevents asthma exacerbations in children. Methods: Retrospective cohort study of 800 children with asthma, where one half did, and the other half did not receive the influenza vaccine. The two groups were compared with respect to clinic visits, emergency department (ED) visits, and hospitalisations for asthma. In multivariable analyses, adjustment was made for baseline asthma severity, prior utilisation of health services, receipt of vaccine in the previous year, and demographic variables. Results: After adjusting for other variables, the vaccine group had a significantly increased risk of asthma related clinic visits and ED visits (odds ratios 3.4 and 1.9, respectively). Conclusion: This study failed to provide evidence that the influenza vaccine prevents paediatric asthma exacerbations.

Neonatal herpes simplex virus (HSV) infection is usually acquired at birth, although a few infants have had findings suggestive of intrauterine infection. We describe 13 babies who had clinical manifestations of intrauterine HSV infection, including skin lesions and scars at birth (12), chorioretinitis (eight), microcephaly (seven), hydranencephaly (five), and microphthalmia (two). All infants had combinations of these defects. Infection was proved by viral isolation in each case; all isolates were HSV-2. Two infants died during the first week of life; 10 of the surviving infants had severe neurologic sequelae, and one infant was blind. Four mothers experienced an apparent primary genital HSV infection, and one had recurrent infection, at varying times during gestation. The remaining women denied a history of symptoms of genital HSV infection. These findings indicate that intrauterine HSV infection can occur as a consequence of either primary or recurrent maternal infection and has severe consequences for the fetus.

Orally administered rhesus rotavirus vaccine (RRV) was evaluated in a placebo-controlled study in 176 infants (ages 2 to 4 months). Eighty-eight infants received a dose of 10(4) plaque-forming units of the vaccine, and 88 received the placebo. RRV was well-tolerated but mildly reactogenic in the 10 days after vaccination. There were mild febrile reactions (greater than or equal to 38 degrees C rectally) in 40% of the vaccinees and in 16% of the placebo recipients (P = 0.001). More of the vaccinees had loose stools than did the placebo recipients (P less than 0.05). RRV was immunogenic and induced a 4-fold or greater rise in serum neutralizing antibody responses in 67% of the vaccinees; however, breast-fed infants were less likely to develop a seroresponse than infants who were not breast-fed. Despite the good immunogenicity of RRV the overall incidence of rotavirus-associated illnesses was similar between the vaccine and placebo recipients. The failure of RRV in Rochester may be related to the fact that the circulating rotaviruses were predominantly serotype 1 and RRV is a serotype 3 rotavirus. Because the serotypes of rotavirus that predominate may vary from year to year, a polyvalent preparation may be necessary to provide effective vaccination against rotaviruses.

Rotavirus is a major worldwide cause of acute gastroenteritis in children. We recently evaluated a rhesus monkey rotavirus (RRV-1) which shares neutralization specificity with human sero-type 3, as a potential vaccine candidate. We administered RRV-1 (106 TCID50) or placebo orally to 40 adult volunteers who had low or undetectable levels of serum neutralizing antibody under double-blind conditions. Volunteers were evaluated daily for signs and symptoms of gastroenteritis, and stools were examined for RRV-1 by ELISA and tissue culture. Administration of RRV-1 did not induce illness. RRV-1 was shed in the stools of 11/21 (53%) vaccinees for 1 to 6 days without transmission of RRV-1 to other subjects, although one placebo recipient shed wild-type rotavirus from a community-acquired infection. Fourfold or greater serum neutralizing antibody rises to RRV-1 were noted in all vaccinees (21/21) and in 1/18 placebo recipients. Serum antibody rises were also demonstrated by immune adherence hemagglutination in 20/21 volunteers who received RRV-1 and in 1/18 who received placebo, and by complement fixation in 17/21 who received RRV-1 and 0/17 who received placebo. Transient asymptomatic serum ALT and AST rises were seen with similar frequencies in RRV-1 (3/21) and placebo (5/19) recipients. Thus, RRV-1 appears to be attenuated and highly immunogenic in young adults, and warrants additional study in children.